Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_911_Библиотеки_им_академика_М_И_Перельмана
.pdf
stage success rate of 89%. The average number of
incontinent episodes per week improved from 12.1
to 2.3 and the Cleveland Clinic incontinent score
(CCIS) improved from 16.5 to 3.8.
SNS is an expensive therapy that requires a
dedicated team for an optimal outcome. It can yield
dramatic improvement in some, and yet provide no
benefit in others.
48,49
51
Percutaneous and transcutaneous tibial
nerve stimulation
Another form of neurostimulation, known as tibial
nerve stimulation, either percutaneous (PTNS)
or transcutaneous (TTNS), has been investigated
(Fig. 14.10). This allows intermittent electrical
stimulation of the tibial nerve at the level of the
ankle. This has become a popular option for those
who have failed to improve with biofeedback, and
for whom a sphincter repair is not indicated. The
percutaneous method requires a needle electrode,
whilst the transcutaneous technique uses an
electrode pad. The former requires delivery from the
hospital outpatient clinic and is the most reported.
The latter is cheaper and may be self-administered
at home. It is believed that both techniques work by
remote stimulation of the sacral plexus via the tibial
nerve. This is then thought to mimic the action of
sacral nerve stimulation.
A large number of single group series have been
published. All have reported encouraging results for
tibial nerve stimulation in the short term. Hotouras
and colleagues52 reported the outcome of 115
patients who had received 12 sessions of PTNS. At
a median follow-up of 26months the median CCIS
had improved from 12 to 9.4 (P <0.0001). ‘Top-up’
treatments were required to maintain efficacy. These
were administered at a median of 12months. The
same group53 reported the outcome of PTNS in those
with urge, passive and mixed faecal incontinence;
25 patients had urge incontinence, the mean CCIS
improved significantly from 11 to 8 (P = 0.019),
those with mixed incontinence (n = 60) also had a
significant improvement in outcome (12.8 to 9.1, P
<0.0001). Those with purely passive incontinence
(n = 15), failed to show a significant improvement in
CCIS (11.5 to 9.4, P = 0.33).
The effect of transcutaneous tibial nerve
stimulation (TTNS) has also been reported.
Significant improvements in small group studies
were reported by several authors.
a small randomised controlled study attempted
to compare PTNS (n = 11) with TTNS (n = 11)
and a sham TTNS (n = 8) device.57 The number
of incontinent episodes and urgency improved
54–56
However,
Incontinence
a
b
Figure14.10 • (a) Percutaneous tibial nerve stimulation;
(b) transcutaneous tibial nerve stimulation.
significantly in the PTNS group when compared to
the others (P = 0.035). The authors suggested that
PTNS is likely to be superior to TTNS.
Unfortunately, doubts have been cast on the
effectiveness of tibial nerve stimulation by two
large randomised controlled trials. Leroi and
colleagues58 compared TTNS with a sham device
in a large double-blinded RCT, which investigated
144 patients. No statistically significant difference
was seen in the mean number of incontinent
episodes. Only 34 (47%) of the active group
achieved a reduction of over 30% in a faecal
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
181
Chapter 14
incontinence severity score against 19 (27%) of the
sham group (P <0.02). The CONFIDeNT study59
reported the outcome of a double-blinded RCT to
compare PTNS with a sham device. A total of 227
patients were randomised to either group. Only 39
(38%) of the active group achieved a greater than
50% reduction in incontinent episodes compared
to 32 (31%) of the sham group (P =0.396). They
concluded that PTNS did not confer any benefit
over sham treatment.
Despite these findings, a small randomised pilot
study compared SNS (n = 23) with PTNS (n = 17).
The authors suggested that both treatment modalities
provided some clinical benefit. Eleven out of 18 of
those who had received SNS and 7 out of 15 who
had received PTNS achieved a greater than 50%
improvement in incontinent episodes.60 More work is
needed to establish the place of tibial nerve stimulation
in the treatment pathway of faecal incontinence.
Injection therapy
Injectable bulking agents were first described for
use in faecal incontinence in 1993. The technique
relies on the bulking effect of the injected materials
with subsequent fibrosis/collagen deposition
helping to enhance continence. These materials
are usually injected into either the submucosa or
the intersphincteric space. It is not clear if clinical
localisation or ultrasound guidance is necessary for
optimal placement A variety of materials have been
used, including autologous fat, glutaraldehyde crosslinked collagen (Contigen™), pyrolytic carbon beads
(Durasphere™) and silicone biomaterial or PTQ™.
A recent Cochrane review looked at the published
literature to support their use.61 Five randomised
trials were assessed with the outcome in 382 patients
reported; no long-term data were available. Four
of the five studies were at an uncertain or high risk
of bias. The authors reported some benefit from
the use of dextranomer in stabilised hyaluronic
acid compared to placebo, but this was offset by a
greater number of adverse events. Despite the relative
simplicity of the procedure, the available data suggest
that the effects of bulking agents appear to be shortlived and of limited efficacy.
The most recent addition to this group has been
the use of polyacrylonitrile (Gatekeeper™), a shapememory hydrophilic material that enlarges to seven
times its initial diameter of 1.2 mm once in contact
with human tissue. An initial single-centre report
showed a sustained improvement in incontinence
and quality of life scores over a mean follow-up
of 33months.62 A larger multicentre observational
study reported the outcome of this device. At
12month’ follow-up, 30/54(56%) patients achieved
a greater than 75% improvement in incontinent
symptoms, and 7 (13%) achieved continence. The
implant extruded in three patients.63 Further work
is needed to determine the effectiveness of this
device in the longer term.
Stoma formation
Antegrade continence enema
This procedure was first described in 1990 for
children.64 The concept of irrigation is to ensure
emptying of the colon and/or rectum to prevent
seepage of stool. Various procedures have been
described to provide an access to the right colon.
Initially, the appendix was used to create a continent
stoma, an ‘appendicostomy’, by invaginating the tip
of the appendix into the caecum to create a oneway valve. The base of the appendix is then brought
out to the abdominal wall and the patient can then
introduce antegrade enemas.64 Other options now
include a caecal or ileal tube.65 This procedure
can also be performed percutaneously guided by
a colonoscope during which a specially designed
catheter (CHAIT Trapdoor™) is introduced into the
caecum using the following method: (1) fixation of
the caecum to the abdominal wall using anchors, (2)
dilatation of the caecostomy site and (3) placement
of a CHAIT trapdoor catheter.66 This minimally
invasive approach has been shown to be safe and
useful for both paediatric patients and adults.
In a recent long-term review of 75 adult patients,
with a median follow-up of 4years, up to 91% of
patients were still performing antegrade enemas,
while maintaining a significant reduction in
incontinence scores compared to preoperative
values.67 However, some morbidity has been reported
with this procedure, the most common being wound
infection and leakage from the ministoma.
End stoma
A stoma is appropriate for patients with severe endstage faecal incontinence in which all other available
treatments have failed, are inappropriate because
of comorbidities, or when preferred by the patient.
While a stoma may be associated with significant
psychosocial issues and stoma-related complications,
it can allow the patient to resume normal activities
and improves quality of life. In a survey of patients
who had a colostomy created to manage their
faecal incontinence, 83% reported a significant
improvement in lifestyle and 84% would choose to
have the stoma again.68 An end sigmoid colostomy
without proctectomy is usually recommended as a
procedure of choice for patients who elect to have
a colostomy. A colostomy, however, can result in its
own problems in some patients, such as diversion
182
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
Incontinence
proctitis and mucus leakage, which may necessitate
a secondary proctectomy. The use of laparoscopic
surgery has reduced the morbidity associated with
this procedure. Recent work suggests that the use
of a prophylactic mesh may reduce the, once near
certain, chance of a parastomal hernia developing.
preferences. Evidence is unfortunately not robust for
most assessment and treatment methods described.
Thus, decision-making often relies on expert
opinion and personal experience, which should in
turn be in the context of a multidisciplinary team
69
of specialists. This is essential for optimising patient
outcomes, with the colorectal surgeon being only a
A colostomy can be a good option for patients
who suffer from severe faecal incontinence, offering
symptom relief with improved quality of life.
part of the support process.
There is active research in this field and new
treatments will soon be available. In the future these
may involve the use of stem cell therapy and newer
sphincter augmentation technologies. Improvement
Conclusion
in our understanding of how neuromodulation
works will allow more refined electrical stimulation
Despite all the currently available treatment
procedures presented and discussed above, each
patient requires an individualised management
approach, taking into account their own needs and
treatments to be developed. A better evidence base
is also needed. Large randomised comparative
studies are needed to evaluate the new treatments
when they emerge.
Key points
• Faecal incontinence (FI) is defined as the involuntary loss of solid or liquid stool.
• The frequency and severity of incontinence episodes and urgency, best assessed with stool diaries,
guide the treatment choice.
• FI is multifactorial: the identification of mechanism and cause of FI is key for subsequent
management.
• Conservative management including dietary counselling, medication and pelvic floor retraining is first-
line. Psychosocial support plays an important role in management of FI.
• Overlapping sphincteroplasty can be offered to patients with significant FI and a documented
sphincter injury, frequently due to obstetric trauma. Most patients improve after sphincteroplasty, but
outcomes deteriorate over time.
• Sacral nerve stimulation is an effective therapy for patients with significant FI in whom conservative
management fails. The technique has the advantage of allowing a therapeutic trial prior to permanent
stimulator implantation.
• Colostomy provides restoration of a more normal lifestyle and improves quality of life. An end
sigmoidostomy alone is recommended. Antegrade colonic enemas can also be an option in refractory FI.
• New technologies such as the magnetic anal sphincter and the Gatekeeper™ bulking agent may
offer an effective treatment option.
Recommended videos:
SNS placement – https://www.youtube.com/
watch?v=EnF5NJaQ-3k
Anal sphincteroplasty – https://www.youtube.com/
watch?v=oiiZ0HoeVPc
Full references available at http://expertconsult.
inkling.com
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
Key references
48. MaedaY, LundbyL, BuntzenS, etal. Outcome of sacral
nerve stimulation for fecal incontinence at 5years. Ann
Surg 2014;259(6):1126–31. PMID: 23817505.
This is one of several studies to demonstrate the
efficacy of SNS in the longer term. It also highlights the
importance of a positive response to treatment by 6
months to predict a good outcome in the long term. This
suggests that good patient selection for SNS is vital.
49. TanE, NgoNT, DarziA, etal. Meta-analysis: sacral
nerve stimulation versus conservative therapy in the
treatment of faecal incontinence. Int J Colorectal
Dis 2011;26(3):275–94. PMID: 21279370.
183
15
15
Functional problems and their surgical
management
Nicola S. Fearnhead
Introduction
Pelvic floor pathology tends to be complex and crosses
several disciplines. Treatment of urogynaecological
pathology in isolation is likely to have an adverse impact
on defaecatory function, and vice versa.1 Ideal care of
women with pelvic floor disorders involves input from
specialist urologists, gynaecologists and colorectal
surgeons, together with allied specialities including
radiology, physiotherapy, specialist nursing expertise,
physiology, gastroenterology, psychiatry and chronic
pain clinics. Preoperative assessment may include
questionnaires on obstetric and urogynaecological
history, constipation and incontinence scoring, visual
analogue scales for pain, quality of life questionnaires,
careful clinical examination, proctoscopy with or
without colonoscopy, defaecography, transit studies,
anorectal physiology and endoanal ultrasound.
Increased understanding of the anatomical and
functional aspects of pelvic floor problems has led
to the establishment of multidisciplinary pelvic floor
clinics and teams.
2
Rectal prolapse
Rectal prolapse or procidentia refers to external
protrusion of the rectum through the anus. Prolapse
is either mucosal, where only the mucosal layer
prolapses, or full-thickness, with circumferential
protrusion through the anus of all linings of the rectal
wall. Rectal prolapse occurs occasionally in young
children but is most common in elderly women.
Risk factors for developing rectal prolapse include
connective tissue disorders, for example Marfan’s
and Ehler’s–Danlos syndromes3 and a history of
anorexia nervosa.4 The latter patients may present
some years after resolution of the psychiatric
disorder, the prolapse resulting from poor crosslinking of collagen fibres in the pelvic floor
musculature during adolescent years. Other risk
factors for developing pelvic organ prolapse include
high body mass index and high birth-weight during
vaginal deliveries.
5,6
Mucosal prolapse
Mucosal prolapse may occur in isolation but is
commonly seen in association with obstructive
defaecation syndrome (ODS) and solitary rectal
ulcer syndrome (SRUS). It may cause symptoms of
perianal discomfort, passage of mucus or blood,
constipation and straining at stool. The treatment of
mucosal prolapse initially involves bulking agents,
increased fibre intake and improving toileting
techniques. If surgical intervention is required,
outpatient procedures such as suction banding
or sclerotherapy or day case procedures such as
surgical excision or plication of the prolapse and
radiofrequency ablation
More recently some patients with mucosal prolapse
and obstructive defaecation have been treated with
the procedure for prolapse and haemorrhoids (PPH)
or stapled transanal rectal resection (STARR).
7–9
are commonly used.
10,11
Full-thickness rectal prolapse (see
Table15.1)
Although conservative treatment with increased
fibre intake and the use of bulking laxatives may
improve symptoms to some extent, the definitive
184
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
Functional problems and their surgical management
Table15.1 • Randomised controlled trials in rectal prolapse surgery
Length of
Authors Year n
follow-up Trial procedures Outcomes
Speakman etal.341991 26 Median 12 months Open polypropylene mesh
rectopexy with division vs
preservation of lateral
ligaments
Luukkonen etal.431992 30 6 months Open resection suture rectopexy
vs open polyglycolic acid mesh
rectopexy
McKee etal.
44
1992 18 Mean 20months Open resection rectopexy vs
open suture rectopexy (with
division of the lateral ligaments)
Selvaggi etal.
35
1993 20 Mean 14 (range
6–24) months
Open Marlex®/Mersilene®
rectopexy with division vs
preservation of lateral
ligaments
Winde etal.
40
1993 49 Mean 50.5 months Open abdominal rectopexy
(with anterior mesh sling)
comparing polyglycolic acid vs
polyglactin mesh
Novell etal.
39
1994 63 Median 47 (range
44–50) months
Open abdominal Ivalon®
sponge rectopexy vs suture
rectopexy
Deen etal.
28
1994 20 Median 17 (8–22)
months
Altemeier’s procedure with
pelvic floor repair vs abdominal
resection rectopexy with pelvic
floor repair
Galili etal.
41
1997 37 Mean 3.7 years Open abdominal mesh rectopexy
(with anterolateral rectal mesh
fixation) comparing polyglycolic
acid vs polypropylene mesh
Boccasanta etal.481998 21 Mean 29.5 (range
8–45) months
Laparoscopic vs open
Marlex®/Mersilene® mesh
rectopexy versus open suture
mesh (with anterolateral rectal
mesh fixation)
Mollen etal.
36
2000 18 Mean 3.5 years Posterior mesh rectopexy with
division vs preservation of
lateral ligaments
Solomon etal.
46
2002 40 Mean 24.2 (range
2–52) months
Laparoscopic vs open abdominal
mesh rectopexy
Lateral ligament preservation
was associated with less
postoperative constipation but
an increased rate of recurrent
prolapse
Resection rectopexy resulted in
less postoperative constipation
Resection rectopexy resulted in
less postoperative constipation
but less improvement in faecal
incontinence
Lateral ligament preservation
was associated with less
postoperative constipation
No significant differences in
postoperative complications or
recurrence rates
No significant difference in
recurrence rates
Significantly higher incidence
of postoperative constipation in
Ivalon® sponge group
Similar recurrent full-thickness
and mucosal prolapse rates
Significant postoperative
morbidity in both groups
Incontinence significantly
improved in resection rectopexy
group only
No significant differences in
postoperative complications or
recurrence rates
No significant difference in
recurrence rates
No statistical difference in
functional outcome
No significant difference in
recurrence rate
Laparoscopic approach was
associated with significantly less
morbidity, shorter hospital stays
and longer operating times
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
185
Chapter 15
Table15.1 • Randomised controlled trials in rectal prolapse surgery—cont’d
Length of
Authors Year n
follow-up Trial procedures Outcomes
Boccasanta etal.212006 40 Mean 28months Altemeier’s procedure with
levatorplasty comparing
monopolar electrocautery
dissection and handsewn
anastomosis vs harmonic
scalpel dissection and circular
stapled anastomosis
Karas etal.
29
2011 252 5 years (10.6%
patients lost to
follow-up)
Transabdominal rectal
mobilisation without rectopexy
vs with rectopexy (mesh or
sutures)
Senapati etal.17
www.prosper.bham.
ac.uk
2013 293 3 years PROSPER (Prolapse Surgery:
Perineal or Rectopexy) trial:
First randomisation or surgeon
preference to select abdominal
vs perineal approach. Second
randomisation in abdominal
approach of suture vs resection
rectopexy and in perineal
approach of Delorme’s vs
Altemeier’s operations
Youssef etal.
27
2013 82 1 year Delorme’s vs Delorme’s with
levatorplasty
Lundby etal.
50
2016 75 1 year (8 patients
withdrew consent
Laparoscopic ventral mesh
rectopexy vs posterior rectopexy
for follow-up)
Emile etal.
18
2017 50 18 months Laparoscopic ventral mesh
rectopexy vs Delorme's
procedure
ODS, obstructive defaecation syndrome.
No significant difference
in functional outcomes or
recurrence rates
Operating time, blood loss and
hospital stay were significantly
reduced in the stapled group
Significantly higher 5-year
recurrence rate in no rectopexy
(8.6%) vs rectopexy group
(1.5%) (P = 0.003)
49 patients randomised to
approach, 78 to abdominal
procedures and 213 to perineal
procedures
Primary endpoint of recurrent
prolapse abandoned in favour
of secondary endpoints of
bowel function and quality of life
when recruitment one-third of
anticipated
No difference in recurrence rates
between surgical methods (19%
abdominal vs 28% perineal) but
overall recurrence rate high
Significantly higher recurrence
rate in Delorme’s group (14.3%)
vs Delorme’s with levatorplasty
(2.4%) (P = 0.043)
Greater improvement in faecal
incontinence symptoms in
Delorme’s with levatorplasty arm
Primary outcome of reduction in
ODS score at 12 months
No significant difference between
groups in primary outcome,
complication rates or recurrence
No difference in incontinence
scores or recurrence rates
treatment for full-thickness rectal prolapse is almost
exclusively surgical. The Cochrane Library’s review
on prolapse surgery failed to identify any trials
comparing surgery to non-operative management.12
Surgical repair may be undertaken either from an
abdominal or perineal approach. The systematic
reviews of Work Programme 4 of the NIHR-funded
CapaCiTY study usefully classify procedures into
those involving rectal suspension, rectal excision or
reinforcement of the rectovaginal septum.
Choice of abdominal or perineal surgical
approaches
The choice of approach has largely been influenced
by the preference of the surgeon as well as patient
factors including comorbidity, age, gender and
186
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
13
Functional problems and their surgical management
sexual activity. Most surgeons used to prefer
perineal procedures in elderly or frail patients and
abdominal approaches in fit patients irrespective of
age,14 although there has been a shift with increasing
evidence that laparoscopic procedures are safe even
in the very elderly.15 The choice of procedure should
also take into account the presence of concurrent
genital prolapse, constipation, evacuatory difficulties,
faecal incontinence and any history of pelvic floor
injury.16 Resection rectopexy has traditionally
been recommended for patients who have both
constipation and rectal prolapse, although there
is little objective evidence to support this practice.
Men may prefer perineal procedures in view of the
potential for erectile dysfunction resulting from
rectal mobilisation during abdominal approaches.
A revised meta-analysis of randomised
controlled trials in prolapse surgery was published by
the Cochrane Library in 2015 but identified only 15
trials with 1007 patients.12 The reviewers had set out
to address the issues of abdominal versus perineal
approaches, rectopexy methods, open versus
laparoscopic approaches, and no resection versus
resection. The paucity of data, small sample sizes
and methodological problems resulted in few useful
conclusions being drawn from the analysis. In
particular, there was no difference in recurrence rates
between abdominal and perineal approaches.12
Quality of life was poorly reported in all the trials
analysed.
The UK’s PROSPER trial recruited 293
patients in a pragmatic trial design where
randomisation occurred at either one or two steps
within the treatment pathway: 48 patients were
randomised to abdominal versus perineal approach,
78 to abdominal resection versus suture rectopexy,
and 212 to perineal procedure: Delorme’s versus
Altemeier’s.17 Recurrence rates overall were high, but
importantly all procedures were associated with an
improvement in quality of life scores. No approach or
individual surgical procedure was found to be
superior with respect to recurrence of prolapse,
quality of life or impact on symptoms of faecal
incontinence.
17
without resection.19 The Altemeier’s procedure
(perineal rectosigmoidectomy) involves dissection
into the peritoneal cavity via the prolapsed peritoneal
lining of the pouch of Douglas, followed by excision
of the rectum and sigmoid colon and a coloanal
anastomosis20 (Figs15.1 and 15.2). The latter is usually
done by hand but is occasionally described with a
circular stapler.
may be used in conjunction with perineal procedures
to treat symptoms of incontinence.
21–23
Pelvic floor repair or levatorplasty
24
Delorme's procedure for full-thickness rectal
prolapse has remained in favour as it is well tolerated
in the elderly, has low morbidity and mortality, and
minimal impact on continence and bowel function.
Recurrence rates after Delorme’s procedure are,
however, high, varying between 5% and 26.5%,
although the procedure may be repeated.
A randomised trial of Delorme’s procedure
versus Delorme’s procedure with levatorplasty in 82
patients found a significant improvement in
postoperative symptoms of faecal incontinence, and
a non-significant trend to lower recurrence rates at
12months, in the second group.
27
25–26
Altemeier’s procedure carries the potential
complication of pelvic sepsis from anastomotic
dehiscence, but nevertheless appears well tolerated,
even in the elderly. The largest published series
report complication rates of 12–14% with very low
A small trial randomising between laparoscopic
ventral mesh rectopexy and Delorme’s procedure
found no difference in complication rates, incontinence
scores or recurrence rates at 18months but was likely
to be under-powered to detect any true difference on
18
its own.
Perineal approaches
The principal perineal approaches are the Delorme’s
and Altemeier’s procedures. Delorme’s procedure
involves resection of the sleeve of redundant rectal
mucosa and plication of the prolapsed muscle wall
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
Figure15.1 • Division of peritoneal reflection during
Altemeier’s procedure.
Reproduced by permission of Dr Tracy Hull, Cleveland
Clinic, Cleveland, Ohio.
187
Chapter 15
Figure15.2 • Resection of rectosigmoid prior to
coloanal anastomosis during Altemeier’s procedure.
Reproduced by permission of Dr Tracy Hull, Cleveland
Clinic, Cleveland, Ohio.
mortality rates and improved continence in around
half of patients, but rates of recurrent prolapse are
still high at 10–16%.
A small randomised trial with a total of 20
participants compared Altemeier’s procedure with
abdominal resection rectopexy, both procedures
being combined with pelvic floor repair.28 One patient
in the Altemeier’s arm had recurrent full-thickness
prolapse although two patients in each arm also
developed mucosal prolapse. Both groups
experienced significant postoperative morbidity, but
symptoms of incontinence were significantly
improved only in the abdominal resection rectopexy
28
group.
Abdominal approaches
Abdominal surgery may be performed either open
or laparoscopically. Abdominal rectopexy entails
rectal mobilisation and fixation to the sacrum with
either sutures or mesh.
A randomised trial of 252 patients confirmed
the traditional view that fixation of the rectum to the
sacrum (rectopexy) is an integral part of the success
of prolapse repair by the transabdominal route.
Rectopexy may be performed either posteriorly
with Ivalon sponge (Wells’ procedure), fascia lata
(Orr Loygue operation) or non-absorbable mesh,
25,26
29
or anteriorly with an anterior mesh sling around the
rectum to the sacrum (Ripstein’s procedure) or ventral
mesh rectopexy. Resection during an abdominal
rectopexy (Frykman Goldberg procedure) usually
involves resection of the sigmoid colon with a handsewn
or stapled anastomosis at the sacral promontory.
A multicentre pooled analysis of 643 patients who
underwent abdominal procedures for rectal prolapse
over a 22-year period found age, gender, surgical
technique, means of approach (open or laparoscopic)
and method of rectopexy had no impact on
recurrence rates.31 Nevertheless, this study was
retrospective and probably not powered to show
significant differences between the different surgical
techniques of rectal mobilisation only, mobilisation
with resection and rectopexy, or mobilisation and
rectopexy.31 Another retrospective meta-analysis
using data from six studies on abdominal approaches
to rectal prolapse repair again found no difference in
recurrence rates with age, sex or surgical
technique.
32
30
Defaecatory disorders are common after abdominal
rectopexy and may present either as novel or
worsening constipation, evacuatory difficulties or
faecal incontinence. Although many studies include
analysis of these problems, the actual extent of
the problem is difficult to quantify. A small series
of 23 patients undergoing abdominal rectopexy
were evaluated prospectively for bowel function:
symptoms of incontinence improved in 82%, 36%
of patients with preoperative constipation improved
with surgery, and 42% developed new onset
constipation.33 Faecal incontinence is reportedly
improved in most series of abdominal rectopexy.
26
Three trials have compared the effects of
conservation versus division (with potential rectal
denervation) of the lateral ligaments during posterior
mesh rectopexy,
34–36
although all studies involved
only small numbers of participants. Two of these trials
found that preservation of the lateral ligaments was
associated with less postoperative constipation,
34,35
although one also found an increased rate of recurrent
prolapse with this technique.34 One small prospective
randomised study found that division of the lateral
ligaments during posterior Teflon® mesh rectopexy
had no impact on postoperative constipation.36 The
latest Cochrane review suggests that lateral ligament
division is associated with lower recurrence rates but
was inconclusive on the outcome of postoperative
constipation.
12
A number of studies have looked at different
methods of rectal fixation during rectopexy. The
principal concern with mesh is infection and extrusion.
Although the incidence of infection is low,
37,38
the
consequences are serious when it occurs. Complete
peritoneal closure over non-absorbable meshes may
188
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
Functional problems and their surgical management
also reduce the incidence of postoperative smallbowel obstruction.
A randomised trial in 63 patients comparing
Ivalon® sponge to suture rectopexy found no
difference in recurrence rates although there was a
significantly higher incidence of postoperative
constipation in the Ivalon® sponge arm.39 The
authors concluded that there was no need to use
prosthetic materials to perform successful
rectopexy.
Two trials looking at the relative benefits of
different types of mesh in rectopexy surgery found
no significant differences in either postoperative
complications or recurrence rates with either
absorbable or non-absorbable meshes.
40,41
Resection is usually performed in combination
with suture rectopexy in view of the theoretical
excess risk of infection if non-absorbable mesh is
used for the rectopexy.38 However, a small series of
35 cases of resection rectopexy with non-absorbable
mesh in young patients reported good functional
outcomes and no instances of mesh infection or
anastomotic leakage.
42
Three trials with a combined total of 115
patients have examined the impact of concomitant
sigmoid resection during open abdominal
rectopexy.
17,43,44
One trial randomised patients
between resection rectopexy and polyglycolic acid
mesh rectopexy43 and the other two compared
resection rectopexy with suture rectopexy.
17,44
If the results of these studies are combined,
there is a statistically significant difference in
rates of surgically induced constipation, with
a lower incidence in the resection arms of each
trial.12 However, one of the trials involved
division of the lateral ligaments,44 which may
in itself have contributed to the high incidence
of postoperative constipation. When measured,
there was no difference in quality of life between
the two procedures.
17
Laparoscopic approaches
Laparoscopic procedures tended to be associated
with fewer complications and shorter length of
stay in the latest Cochrane review.12 A metaanalysis conducted to compare open and
laparoscopic rectopexy in 688 patients45 included
12 studies, only one of which was prospective and
randomised.46 The rectopexy techniques included
resection, suture and mesh. The meta-analysis
concluded that laparoscopic rectopexy was
safe, took longer and had comparable recurrent
prolapse rates compared to open surgery.45
Surgeon preference for the laparoscopic abdominal
approach has become well-established in the UK.
47
Two small randomised trials have compared
open and laparoscopic approaches to mesh
rectopexy.
involved anterolateral rectal fixation of nonabsorbable mesh to the sacral promontory and found
no difference in recurrence rates between the
different approaches at just over 2 years.48 The
second trial (40 patients) described full rectal
mobilisation with posterior mesh rectopexy to the
sacral promontory with a single spiked chromium
staple and lateral fixation with hernia staples.46 It too
confirmed no difference in recurrence rates at 2years
(with one recurrence in the open group) but did show
that the laparoscopic approach was associated with
significantly less morbidity, a shorter hospital stay but
a longer operating time.
46,48
The first small trial (21 patients)
46
Improved quality of life is an essential outcome
after prolapse surgery but, to date, has only been
reported in one trial.17 Case series suggest that use
of the laparoscopic approach may have a significant
impact in terms of improving quality of life.
Only one Danish trial has compared the
laparoscopic procedures of posterior sutured
rectopexy and ventral mesh rectopexy: 75 patients
with full-thickness prolapse were randomised.50 The
primary outcome selected was change between
pre- and postoperative obstructive defaecation
syndrome scores. There was no difference in
functional outcomes, complication rates or
recurrence rates at 12months.50 Colonic transit time
increased in both groups, but to a significantly lesser
extent in the ventral rectopexy arm.50 Some concern
has been raised about the quality of surgery in the
ventral mesh rectopexy arm as participating
surgeons had performed only ten of these
procedures prior to the trial.
49
A feasibility study has examined the technique
of robot-assisted laparoscopic rectopexy and
concluded that robotic rectopexy can be safely
undertaken with similar functional outcomes but
higher recurrence rates than open rectopexy.51 A
small trial of laparoscopic versus robotic ventral
mesh rectopexy in 30 patients, of whom only six
had full-thickness prolapse, found that the robotic
approach was safe and produced good anatomical
correction, but without assessing functional
outcomes.52 The additional cost of robotic surgery
still needs justification with health economic
modelling.
53
The surgical management of combined rectal and
urogenital prolapse is probably best carried out from
an abdominal approach and laparoscopic repairs
are particularly suitable for repairing abnormalities
of the rectum, vagina, bladder and pelvic floor.
54,55
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
189
Chapter 15
The advantages of laparoscopic approaches in
these patients include nerve-sparing surgery and
minimally invasive surgery. A combined approach
may also serve to lessen the impact of prolapse
repair in one compartment on symptoms in another.
If mesh is used, ideally procedures that open the
vagina should be avoided to reduce the chances of
mesh erosion. Vaginal hysterectomy in the setting
of combined rectal and urogynaecological prolapse
surgery may be associated with higher morbidity.
56
Recurrent rectal prolapse
Recurrence rates following rectal prolapse surgery
vary widely. As all of the approaches carry a risk
of recurrent rectal prolapse, a number of patients
will come to a second procedure. There is, however,
little in the reported literature on management of
recurrent rectal prolapse. Abdominal approaches are
used more commonly than perineal approaches for
recurrent full-thickness prolapse by some groups,57
while others point out that perineal procedures can
be safely repeated.58 Recurrent prolapse in more
than one compartment may be best treated by an
abdominal approach.59 Irrespective of approach,
surgery for recurrent prolapse carries a significant
risk of postoperative bowel dysfunction, either with
obstructive or incontinent symptoms.
57,58
Obstructive defaecation,
rectocele and rectal
intussusception
The cardinal symptoms of obstructive defaecation
are straining at stool, a sense of incomplete
evacuation and the need for rectal, vaginal or
perineal digitation in order to achieve evacuation.
Paradoxical contraction of the puborectalis muscle
during straining at stool is better termed pelvic
floor dyssynergia. The latter is more commonly
associated with urogynaecological, gastrointestinal
and psychological problems than with slow-transit
constipation. Many ‘constipated’ patients will have
improvement in their symptoms with treatment
of obstructive defaecation. The treatment is
predominantly medical with dietary manipulation,
use of laxatives and biofeedback training.
An anterior rectocele and/or rectal intussusception
(internal rectal prolapse) are often found in
association with obstructive defaecation symptoms.
Nevertheless, the syndrome is very complex and
symptomatology variable. Symptoms of obstructive
defaecation may mask a number of occult disorders
including anxiety and depression, gynaecological
prolapse, anismus, rectal hyposensitivity and slowtransit constipation. Many problems associated with
obstructive defaecation may not be immediately
apparent.61 Recognition and anticipation of occult
60
pathology allows treatment to be tailored to the
individual patient.
Objective assessment of the symptoms of
obstructive defaecation is particularly important
when trying to assess the impact of new surgical
interventions for the condition. The Cleveland Clinic
Constipation Scoring System is already widely used
but is not specific for obstructive defaecation.62
One, as yet unvalidated, scoring system using a
structured questionnaire gives weight to time spent
at defaecation, the number of attempts at defaecation
each day, use of digitation, use of laxatives and
enemas, the presence of incomplete evacuation,
straining at stool and stool consistency.63 The Patient
Assessment of Constipation Quality of Life (PACQoL) consists of 28 items covering four principal
domains: worries and concerns, physical discomfort,
psychosocial discomfort and satisfaction.64 PACQoL is currently the validated outcome measure of
choice when assessing obstructive defaecation.
Rectocele
A rectocele is a hernia of the anterior rectal wall
bulging into the rectovaginal septum. It arises
from muscular and nerve damage sustained during
vaginal delivery, as a result of hormonal changes
following the menopause, or due to paradoxical
contraction of puborectalis. Rectoceles occur due to
a pressure gradient between the rectum and vagina
during coughing and straining and weakness in
the puborectalis and bulbocavernosus muscles.65
Suspensory surgery on the anterior vaginal wall (e.g.
anterior colporrhaphy or Burch colposuspension)
may predispose to the development of a rectocele.66
Posterior rectoceles are rarely found, and usually
result from traumatic injury or surgical interventions
breaching the anococcygeal ligament.
An anterior rectocele is a common finding in
patients with obstructive defaecation syndrome, but
may also occur in asymptomatic patients. It is often
seen on defaecography67 and magnetic resonance
proctography.68 Symptoms associated with rectocele
include difficulty in evacuation, constipation,
the need for perineal or vaginal digitation during
defaecation and rectal discomfort. Rectoceles vary
in size, both in the extent of protrusion into the
vagina and in the length of involvement of the
rectovaginal septum, but size does not correlate
with symptom severity.
The majority of patients with symptoms
of obstructive defaecation and an associated
rectocele will respond to dietary manipulation
and biofeedback.
to improved defaecatory symptoms in selected
patients who have failed to respond to conservative
treatment.72 Surgical repair by either gynaecologists
69–71
Rectocele repair may lead
190
Downloaded for Anonymous User (n/a) at Rutgers University - NERL from ClinicalKey.com by Elsevier on March 22, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
Соседние файлы в папке Библиотека им академика М.И. Перельмана