N. Wijffels

Laparoscopic ventral rectopexy for internal rectal prolapse: short-term functional results

Objective  Over the last 15 years, posterior rectopexy, which causes rectal autonomic denervation, was discredited for internal rectal prolapse because of poor results. The condition became medical, managed largely by biofeedback. We aimed to audit the short‐term functional results of autonomic nerve‐sparing laparoscopic ventral rectopexy (LVR) for internal rectal prolapse.

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.

What is the natural history of internal rectal prolapse

Aim  The nature and clinical significance of internal rectal prolapse is controversial. Its natural history is unclear. Longitudinal cohort studies show rare progression to external prolapse but lack adequate follow‐up. We aimed to study the relationship of age to various stages of internal rectal prolapse using the Oxford Rectal Prolapse Grade (ORPG) and evaluate the influence of sex and vaginal delivery on this relationship.

What are the symptoms of internal rectal prolapse

Aim  Although high‐grade internal rectal prolapse is believed to cause functional symptoms such as obstructed defaecation, little has been published on the exact distribution and frequency of symptoms. The aim of this study was to identify the most common symptoms of patients with high‐grade internal rectal prolapse.

Local gentamicin reduces perineal wound infection after radiotherapy and abdominoperineal resection

BackgroundPerineal wound complications are frequently observed after abdominoperineal resection (APR) for rectal cancer, especially in preoperatively irradiated patients. This is the first study to investigate whether local application of gentamicin-impregnated collagen fleece reduces deep perineal wound infection after APR for rectal cancer following short-term radiotherapy.MethodsBetween 2003 and 2007, a consecutive series of 40 patients underwent an APR for rectal cancer after short-course radiotherapy in our hospital. Of these patients, 19 received supplementary application of three reabsorbable gentamicin-impregnated collagen fleece sponges into the sacral cavity before closure of the perineum (group A), and 21 patients underwent primary closure of the perineal wound and served as a control group (group B). All patients received sacral drainage. A superficial perineal wound infection was defined as cellulitis with no evidence of deep tissue infection. A deep perineal wound infection was defined as skin and subcutaneous tissue breakdown with infection extending deep into the subcutaneous tissue or a wound abscess.ResultsThe two groups were comparable regarding age, sex, tumour stage and level of the tumour. No postoperative mortality was observed in either group. Primary wound healing occurred in 16 patients (84%) in the gentamicin group and 9 patients (43%%) in the control group (p=0.01). The incidences of superficial perineal wound complications were 11% (two patients) in group A who received local application of gentamicin and 29% (six patients) in group B (p=0.15). Six patients (29%) in group B developed a deep infection or wound abscess, resulting in full dehiscence of the wound and sacral cavity. This devastating complication occurred in only one patient (5%) in group A (p=0.05). In most patients deep perineal wound infection was treated with vacuum therapy or drainage. The mean hospital stay of the gentamicin group was 15 days and of the control group 25 days (p=0.04).ConclusionsBased on the results of this study, we recommend local application of gentamicin in the sacral cavity in patients who undergo abdominoperineal resection after shortterm radiotherapy.

Impact of slow transit constipation on the outcome of laparoscopic ventral rectopexy for obstructed defaecation associated with high grade internal rectal prolapse.

Limited literature exists on whether slow colonic transit adversely influences the results of outlet obstruction surgery. We compared the functional results of laparoscopic ventral rectopexy (LVR) for obstructed defaecation secondary to high grade internal rectal prolapse in patients with normal and slow colonic transit.

Excellent response rate of anismus to botulinum toxin if rectal prolapse misdiagnosed as anismus (‘pseudoanismus’) is excluded

Aim  Anismus causes obstructed defecation as a result of inappropriate contraction of the puborectalis/external sphincter. Proctographic failure to empty after 30 s is used as a simple surrogate for simultaneous electromyography/proctography. Botulinum toxin is theoretically attractive but efficacy is variable. We aimed to evaluate the efficacy of botulinum toxin to treat obstructed defecation caused by anismus.

Rectal hyposensitivity is uncommon and unlikely to be the central cause of obstructed defecation in patients with high-grade internal rectal prolapse

Background  There are several causes of obstructed defecation one of which is thought to be internal rectal prolapse. Operations directed at internal prolapse, such as laparoscopic ventral rectopexy, may improve obstructed defecation symptoms significantly. It is not clear whether the obstructed defecation with internal prolapse is a mechanical phenomenon or whether it results changes in rectal sensitivity. This study aimed to evaluate rectal sensory function in patients with obstructed defecation and high‐grade internal rectal prolapse.

Enterocoele is a marker of severe pelvic floor weakness

Objective  The aim was to evaluate the relationship between the presence of an enterocoele and grade of rectal prolapse (RP).

Reply to: Rectocele repair by anterolateral rectopexy; long-term functional outcome (Oom et al.)

Dear Sir, We read with great interest the paper on anterior rectopexy by Oom et al. [1]. Reassuringly, abdominal repair of rectocoele does not cause sexual dysfunction. However, only one in three patients obtained symptomatic relief of obstructed defaecation, despite radiological demonstration of adequate repair, similar to the previous work on this indication [2]. Your results support our view that rectocoele is not the central pathological lesion in patients with the descending perineal syndrome. Interestingly, your work on isolated correction of enterocoele at the pelvic inlet, with 25% symptom relief of obstructed defaecation, also supports this view [3]. We believe that internal or occult rectal prolapse (or rectal intussusception) is the central patho-anatomical lesion in descending perineum. Unfortunately, a traditional view considers internal prolapse as a variant of normal [4], despite recent evidence to the contrary [5]. In our experience, rectocoele almost always coexists with internal rectal prolapse, and is found in isolation in only about 10% of patients with obstructed defaecation; enterocoele is almost invariably associated with, and a marker of, advanced pelvic floor weakness, rather than a cause of obstructed defaecation. Thus surgery should be directed at the central lesion and the internal prolapse corrected. This is achieved with anterior or ventral rectopexy, which at the same time treats the coexisting abnormalities of rectocoele (obliterated by mesh in the rectovaginal septum) and enterocoele (cured by elevated reconstruction of the peritoneal incision). When the central lesion is targeted, cure rates are in the order of 75–80% [6,7]. When performed laparoscopically, the benefits are greater still [8].