Bertrand Trilling

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, PubMed, 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.

Dynamic cystocolpoproctography to confirm the efficacy of laparoscopic rectopexy in the treatment of hedrocele associated with full-thickness rectal prolapse

Hedrocele literally means anal hernia (from the Greek hedros, meaning anus, and kele, meaning hernia). It is an extremely rare form of hernia with only four cases previously reported [1–3]. Like enterocele, hedrocele is a variant of the rare posterior perineal hernias, resulting from a defect in the rectovaginal septum [3]. A peritoneal pouch containing the small bowel protrudes in the anterior wall of the rectum through the anus. Clinical presentation may be with symptoms and signs of a strangulated small bowel in the hedrocele [3]. Diagnosis can be made by dynamic cystocolpoproctography, which has been shown to be superior to MRI in this context [4]. The aim of this short report is to confirm the efficacy of laparoscopic rectopexy in the management of hedrocele after dynamic cystocolpoproctography.

Videodefecography is still superior to magnetic resonance defecography in the study of obstructed defecation syndrome

We read with interest the article by Martín-Martín et al. [1] reporting on evaluation of the diagnostic accuracy of magnetic resonance (MR) defecography and videodefecography (VD) in obstructed defecation syndrome (ODS). Based on their experience and partial review of the literature, the authors conclude that MR defecography is the imaging modality of choice for evaluating patients with ODS. Our experience in pelvic floor imaging [2, 3] and rectal prolapse repair [4–7], and the attentive reading of the methodology and results reported by the authors, showing many weaknesses and deficiencies, lead us to make some comments and criticisms on this article. Concerning clinical biases, our first question is why 2 men were included in the study, as in men there is of course no rectocele nor cystocele or perineal descent. Therefore, the rectocele rates for VD and MR defecography are not 90 and 92.5%, but 95 and 97%, respectively. Second, there is no mention on the use of enemas, suppositories, medical treatment or physiotherapy. Third, 13 patients had a history of hysterectomy, and 10 further patients had a history of another kind of pelvic surgery; our question is: had some of them had a rectopexy, because postoperative obstructed defecation in those cases might be due to true rectoanal intussusception, but also to many other factors, such as mesh tension, denervation, pelvic inflammation, akinesia, or postoperative transit constipation [8]. Fourth, in our experience, clinical examination of patients with defecation disorders should include perineal inspection with the patient squatting over a bedpan during maximal straining and on defecation. This is the best way to demonstrate rectocele, enterocele, or cystocele; the abnormalities shown in both figures from the article would have been clinically evident. Fifth, we miss anorectal manometry and colonic transit time studies in this paper, as these tests are of great value in defining ODS, anismus, and slow transit constipation. This raises two questions: how did the authors exclude slow transit constipation and how do they explain that a majority of their patients had hard stools of type 2 on the Bristol stool scale? We would like to point out that the number one cause of ODS is slow transit time constipation. Concerning the biases in the techniques, we would first like to emphasize that VD is not adequate for diagnosing pelvic floor disorders; to allow a comparison with MR defecography, it is imperative that the conventional imaging modality be a cystocolpoproctography [2]. Second, the definitions of pelvic floor disorders used by the authors are inadequate: we know from the literature that some images could be the normal pattern, particularly in the case of lowgrade rectocele and intussusception, which can be present in a third of normal volunteers: specific symptoms have to be present and attributable to the internal prolapse or rectocele to establish pathologic significance [4]. Therefore, we totally disagree with calling rectocele a less than 3 cm “out pouching of the anterior rectal wall,” or intussusception all “rectum showing a funnel-shaped depression within the anal canal during push,” if observed, for example, at the end of a complete rectal evacuation. This is probably why the authors found that more than 90% of patients suffered from rectocele! Moreover, intussusception can be seen only in rectal evacuation, which is not always the case in MR defecography for ODS. Still concerning the definitions, we would emphasize that peritoneocele is not pelvic herniation of mesenteric fat, but the simple fact that the peritoneum of the pouch of Douglas is too deep and creates a herniation between the rectum and the vagina; then, enterocele or sigmoidocele are peritoneocele. Third, it is not surprising that cystoceles were seen on MR defecography (like on figure 1 * J.-L. Faucheron JLFaucheron@chu-grenoble.fr

What is fast track multimodal management of colorectal cancer surgery in real life

We read recently an article comparing short-term outcome of laparoscopic surgery for colorectal cancer with a multimodal full fast track (FFT) or limited fast track (LFT) care program [1]. Based on a meta-analysis of the literature, the authors hypothesized decreased postoperative morbidity after the FFT program. According to the results of this multicenter, single-blinded, randomized, superiority trial, the authors delivered the message that a multimodal FFT program might not have any benefit during laparoscopy for colorectal cancer, as compared with a LFT program. Our experience of FFT in colorectal surgery [2] leads us to make some comments on this article. First of all, the authors based their hypothesis around a decreased postoperative morbidity rate reported in a metaanalysis published in 2009. Four randomized clinical trials that had been published since, and before the beginning of Miggiori and colleagues’ study, should have been taken into account as incorporation of their findings may have lead to a different sample size for the study [3–6]. Second, we believe it is not possible to conducte this as a single blind study, a comment already made by Dieter Hahnloser at the end of the paper [1]. Surgeons, anesthetists, nurses, dieticians, and physiotherapists are involved in enhanced recovery programs and, therefore, the study could not be blinded. As a simple example, if the patient is sitting beside his bed and eating on the evening of the operation, we are sure he has been randomized in the FFT group! Moreover, it is stated that the “operating surgeon was blinded to the randomization process”, but it is also mentioned further that there was “infiltration of surgical wounds with Ropivacaine” in the FFT group, which by definition is not blind. Third, we do not understand why 10% of patients who had a colectomy for cancer had a stoma, considering exclusion criteria of emergency, obesity, denutrition, unfit patients, and high-grade tumors. More than 55% of the patients in the entire cohort had a stoma. Fourth, mean operation time was significantly longer in the FFT group. This means that the operations in this group were more complex, or were performed in more complicated cases, or by less expert surgeons or anesthetists, or that some factors were not taken into account in the trial. The longer the operation lasts, the less chance for ambulatory or fast track management, and the more frequent complications are. This factor in itself could explain why at the end there was no difference between the two groups. Fifth, FFT includes 20 items that were clearly described by Kehlet in 1997 [7]. We can see that the most important items in the FFT and LFT were applied in the study. Antibiotic prophylaxis and thromboprophylaxis were not cited, but we presume that the authors followed these guidelines. In the study the differences between FFT and LFT only concern a few minor items. Compared to FFT, LFT comprised absence of preoperative specific information, routine preanesthetic medication, no preoperative carbohydrate loads, free per-operative intravenous fluid infusion, standard peroperative hemodynamic optimization, no intravenous infusion of lidocaine, no ropivacaine infiltration, free opiate analgesia, and progressive mobilization and oral intake starting on postoperative day 1 instead of day 0. A major criticism of this study is the absence of anesthesists as coauthors. A fast track program is clearly a multidisciplinary management of the patients. Hence, we cannot be sure that anesthesists were not applying what is now considered as the gold standard during colorectal surgery, for instance optimal per-operative fluid infusion regime and hemodynamic monitoring [3]. The authors do not mention whether or not * Jean-Luc Faucheron JLFaucheron@chu-grenoble.fr

Similar length of colon is removed regardless of localization in right-sided colonic cancer surgery: Removal of similar length of colon

Colorectal cancers represent a heterogenous group of tumours. While left segmental colectomy is an accepted and oncologically safe practice for left‐sided colonic cancer (CC), some authors suggest that limited segmental resection of right‐sided cancer should be debated in order to preserve length of the resected colon. To our knowledge, caecum and ascending CC have not been analysed as different groups of tumours. The objective of this study was to assess if, retrospectively, surgical treatment of caecal cancer differed from ascending CC.

Critical Aspects of Modern Surgical Approach to Hemorrhoids

Debate still continues in 2017 as to which is the best surgical procedure for the treatment of symptomatic hemorrhoids. Hemorrhoidectomy, first published by Milligan and Morgan, has been the only surgical treatment for hemorrhoids during nearly 50 years and is still considered as the main option. However, this “conventional” hemorrhoidectomy is associated with significant postoperative pain, perianal discharge, irritation, and late complications such as anal incontinence and stenosis. In an effort to decrease postoperative complications and to better respond to hemorrhoids pathophysiology, several procedures have emerged in the end of the twentieth century and can be considered as modern surgical approach to hemorrhoids. These procedures are thermofusion hemorrhoidectomy, Doppler-guided hemorrhoidal artery ligation, suture ligation and mucopexy without Doppler guidance, stapled hemorrhoidopexy, and embolization. In summary, the less painful the procedure, the more likely it is to be associated with recurrence, so that there is not a “one-size-fits-all” option. The aim of this chapter is to present the technique, advantages, drawbacks, and results of all these procedures, based on a recent review of the literature and our personal experience. The main question when facing a patient with hemorrhoids should be: which surgical options for which patients and which hemorrhoids. . .

Robots for rectopexy: probably hindrance... till now!

We thank Doctors Ian Lindsey and Aisling M. Hogan for their comments concerning our article recently published in Techniques in Coloproctology (1) they published in Annals of Laparoscopic and Endoscopic Surgery under the title “ robots for rectopexy: help or hindrance? ” (2).

[Intestinal obstruction, an overview].

Intestinal obstruction is a pathology commonly encountered in emergency and surgical departments. Its origin is usually mechanical, caused by obstruction of the digestive tract. It is a therapeutic emergency. Surgical treatment is required for the most severe cases.