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37 Deciding onanIRA vs. IPAA forFAP
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Personal View oftheData
When patients with FAP need an operation, the decision for proctocolectomy with IPAA or end ileostomy, or preservation of the rectum with IRA, is guided largely by the anticipated oncological and functional outcomes related to each operation. It is important that the surgeon and patient to recognize that one operation does not t all FAP patients: some need more (IPAA or end ileostomy) and others will do better with less (IRA).
FAP patients with <1000 colorectal adenomas, <20 rectal adenomas, and no colon or rectal cancer, should do well with an IRA.This is a relatively simple opera­tion, without need for a diverting ileostomy, less postoperative complications, and more favorable functional outcomes compared to IPAA.Alternatively, in patients with >1000 colorectal adenomas, or more than 20 rectal adenomas, or colon or (particularly) rectal cancer, or high-risk for desmoid tumor formation, proctocolec­tomy with IPAA or end ileostomy are often better surgical options.
The decision on IPAA or end ileostomy involves consideration of the patients’ base-line anal sphincter function (e.g., their ability to defer defecation), their prefer­ence for one operation versus another, and an assessment of the anticipated com­plexity of the planned surgical procedure. For example, in the obese, male FAP patient, with distal rectal high-grade dysplasia or cancer, for whom mucosectomy with sutured IPAA may be the ideal cancer-preventing operation, it may be techni­cally impossible to perform due to the inability of an ileal pouch to reach to the mid anal canal. The decision on stapled or hand sewn IPAA (with distal rectal mucosec­tomy) also warrants consideration of the outcomes of each approach as more favor­able functional outcomes are expected with a stapled IPAA and no guarantee against rectal remnant cancer development even after mucosectomy.
When proctocolectomy is indicated, the option of a permanent end ileostomy may be preferable for some patients who have considered the pros and cons of each operation. For example, with an IPAA, 5–7 bowel movements per day and 1–2 that awaken the patient from sleep, should be expected. This frequency of bowel move­ments may be unacceptable to some patients who may then choose an end ileos­tomy. Finally, in the young female patient, with say hundreds of colon adenomas or 20–30 rectal adenomas without high-grade dysplasia or cancer, a staged approach, starting with IRA, then annual rectal endoscopic surveillance, and eventual proctec­tomy, as needed, may be the best strategy to prevent cancer while also limiting interference with pregnancy and childbirth.
References
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12. Björk J, Åkerbrant H, Iselius L, etal. Outcome of primary and secondary ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis. Dis Colon Rectum. 2001;44(7):984–92. https://doi.org/10.1007/BF02235487.
13. Konishi T, Ishida H, Ueno H, etal. Feasibility of laparoscopic total proctocolectomy with ileal pouch–anal anastomosis and total colectomy with ileorectal anastomosis for familial adenoma­tous polyposis: results of a nationwide multicenter study. Int J Clin Oncol. 2016;21(5):953–61.
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15. Hassan I, Chua HK, Wolff BG, etal. Quality of life after ileal pouch-anal anastomosis and ileorectal anastomosis in patients with familial adenomatous polyposis. Dis Colon Rectum. 2005;48(11):2032–7. https://doi.org/10.1007/s10350- 005- 0169- 7.
16. Ko CY, Rusin LC, Schoetz DJ, etal. Does better functional result equate with better qual­ity of life? Implications for surgical treatment in familial adenomatous polyposis. Dis Colon Rectum. 2000;43(6):829–37. https://doi.org/10.1007/bf02238022.
17. Madden MV, Neale KF, Nicholls RJ, etal. Comparison of morbidity and function after col­ectomy with ileorectal anastomosis or restorative proctocolectomy for familial adenomatous polyposis. Br J Surg. 2005;78(7):789–92.
18. Aziz O, Athanasiou T, Fazio VW, et al. Meta-analysis of observational studies of ileorec­tal versus ileal pouch-anal anastomosis for familial adenomatous polyposis. Br J Surg. 2006;93(4):407–17. https://doi.org/10.1002/bjs.5276.
19. Hartley JE, Church JM, Gupta S, McGannon E, Fazio VW, Phillips RKS. Signicance of incidental desmoids identied during surgery for familial adenomatous polyposis. Dis Colon Rectum. 2004;47(3):334–40. https://doi.org/10.1007/s10350- 003- 0063- 0.
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37 Deciding onanIRA vs. IPAA forFAP
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20. Nieuwenhuis MH, Lefevre JH, Bülow S, etal. Family history, surgery, and APC mutation are risk factors for desmoid tumors in familial adenomatous polyposis: an international cohort study. Dis Colon Rectum. 2011;54(10):1229–34. https://doi.org/10.1097/DCR.0b013e318227e4e8.
21. Sommovilla J, Liska D, Jia X, etal. Ileal Pouch anal anastomosis is more “Desmoidogenic” than ileorectal anastomosis in familial adenomatous polyposis. Dis Colon Rectum. 2021; Publish Ah:1351–1361. https://doi.org/10.1097/dcr.0000000000002172.
22. Burgess A, Xhaja X, Church J.Does intra-abdominal desmoid disease affect patients with an ileal pouch differently than those with an ileorectal anastomosis? Dis Colon Rectum. 2011;54(11):1388–91. https://doi.org/10.1097/DCR.0b013e31822f8d91.
23. Vasen HFA, Möslein G, Alonso A, et al. Guidelines for the clinical management of famil­ial adenomatous polyposis (FAP). Gut. 2008;57(5):704–13. https://doi.org/10.1136/
gut.2007.136127.
24. Vogel J, Church JMLL.Minimally invasive pouch surgery predisposes to desmoid tumor for­mation in patients with familial adenomatous polyposis. Dis Colon Rectum. 2005;48:662.
25. Saito Y, Hinoi T, Ueno H, etal. Risk factors for the development of Desmoid tumor after colec­tomy in patients with familial adenomatous polyposis: multicenter retrospective cohort study in Japan. Ann Surg Oncol. 2016;23:559–65. https://doi.org/10.1245/s10434- 016- 5380- 3.
26. Walter T, Zhenzhen Wang C, Guillaud O, et al. Management of desmoid tumours: a large national database of familial adenomatous patients shows a link to colectomy modalities and low efcacy of medical treatments. United Eur Gastroenterol J. 2017;5(5):735–41. https://doi.
org/10.1177/2050640616678150.
27. Da Luz MA, Church JM, Burke CA.The evolution of prophylactic colorectal surgery for famil­ial adenomatous polyposis. Dis Colon Rectum. 2009;52(8):1481–6. https://doi.org/10.1007/
DCR.0b013e3181ab58fb.
28. Xie M, Chen Y, Wei W, et al. Does ileoanal pouch surgery increase the risk of desmoid in patients with familial adenomatous polyposis? Int J Color Dis. 2020;35(8):1599–605. https://
doi.org/10.1007/s00384- 020- 03578- y.
29. Fábio GC.Surgical treatment of familial adenomatous polyposis: dilemmas and current rec­ommendations. World J Gastroenterol. 2014;20(44):16620–9. https://doi.org/10.3748/wjg.
v20.i44.16620.
30. Church J, Burke C, McGannon E, Pastean O, Clark B.Risk of rectal cancer in patients after colectomy and ileorectal anastomosis for familial adenomatous polyposis: a function of available surgical options. Dis Colon Rectum. 2003;46(9):1175–81. https://doi.org/10.1007/
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31. Sinha A, Tekkis PP, Rashid S, Phillips RKS, Clark SK.Risk factors for secondary proctectomy in patients with familial adenomatous polyposis. Br J Surg. 2010;97(11):1710–5. https://doi.
org/10.1002/bjs.7202.
32. Bülow C, Vasen H, Järvinen H, Björk J, Bisgaard ML, Bülow S.Ileorectal anastomosis is appropriate for a subset of patients with familial adenomatous polyposis. Gastroenterology. 2000;119(6):1454–60. https://doi.org/10.1053/gast.2000.20180.
33. Koskenvuo L, Renkonen-Sinisalo L, Järvinen HJ, Lepistö A.Risk of cancer and secondary proctectomy after colectomy and ileorectal anastomosis in familial adenomatous polyposis. Int J Color Dis. 2014;29(2):225–30. https://doi.org/10.1007/s00384- 013- 1796- 4.
34. Debinski HS, Love S, Spigelman AD, Phillips RKS.Colorectal polyp counts and cancer risk in familial adenomatous polyposis. Gastroenterology. 1996;110(4):1028–30. https://doi.
org/10.1053/gast.1996.v110.pm8612989.
35. Wu JS, Paul P, McGannon EA, Church JM. APC genotype, polyp number, and surgi­cal options in familial adenomatous polyposis. Ann Surg. 1998;227(1):57–62. https://doi.
org/10.1097/00000658- 199801000- 00009.
36. Church J, Burke C, McGannon E, Pastean O, Clark B, Cohen Z.Predicting polyposis sever­ity by proctoscopy: how reliable is it? Dis Colon Rectum. 2001;44(9):1249–52. https://doi.
org/10.1007/bf02234779.
37. Talseth-Palmer BA.The genetic basis of colonic adenomatous polyposis syndromes. Hered Cancer Clin Pract. 2017;15(1):1–7. https://doi.org/10.1186/s13053- 017- 0065- x.
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38. Nieuwenhuis MH, Mathus-Vliegen LM, Slors FJ, etal. Genotype-phenotype correlations as a guide in the management of familial adenomatous polyposis. Clin Gastroenterol Hepatol. 2007;5(3):374–8. https://doi.org/10.1016/j.cgh.2006.12.014.
39. Church JM. Controversies in the surgery of patients with familial adenomatous polypo­sis and lynch syndrome. Familial Cancer. 2016;15(3):447–51. https://doi.org/10.1007/
s10689- 016- 9886- 4.
40. Möslein G.Surgical considerations in FAP-related pouch surgery: could we do better? Familial Cancer. 2016;15(3):457–66. https://doi.org/10.1007/s10689- 016- 9904- 6.
41. Van Duijvendijk P, JFM S, Taat CW, Oosterveld P.Functional outcome after colectomy and ileorectal anastomosis compared with proctocolectomy and ileal pouch anal anastomosis in familial adenomatous polyposis. Ann Surg. 1999;230(5):648–54.
42. Olsen K, Juul S, Bülow S, etal. Female fecundity before and after operation for familial adenomatous polyposis. Br J Surg. 2003;90(2):227–31. https://doi.org/10.1002/bjs.4082.
43. Rajaratnam SG, Eglinton TW, Hider P, Fearnhead NS.Impact of ileal pouch-anal anastomosis on female fertility: meta-analysis and systematic review. Int J Color Dis. 2011;26(11):1365–74.
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44. Melnitchouk N, Saadat LV, Bleday R, Goldberg JE. A decision analysis for rectal-sparing familial adenomatous polyposis: total colectomy with Ileorectal anastomosis versus proc­tocolectomy with IPAA. Dis Colon Rectum. 2019;62(1):27–32. https://doi.org/10.1097/
DCR.0000000000001186.
45. Dossa F, Morris AM, Wilson AR, Baxter NN.Life after surgery: surgeon assessments of quality of life among patients with familial adenomatous polyposis. Dis Colon Rectum. 2018;61(10):1217–22. https://doi.org/10.1097/DCR.0000000000001146.
46. Kuruvilla K, Osler T, Hyman NH.A comparison of the quality of life of ulcerative coli­tis patients after IPAA vs ileostomy. Dis Colon Rectum. 2012;55(11):1131–7. https://doi.
org/10.1097/DCR.0b013e3182690870.
47. Murphy PB, Khot Z, Vogt KN, Ott M, Dubois L.Quality of life after total proctocolectomy with ileostomy or IPAA: a systematic review. Dis Colon Rectum. 2015;58(9):899–908. https://
doi.org/10.1097/DCR.0000000000000418.
48. Seidel S, Newman M, Sharp K.Ileoanal pouch versus ileostomy: is there a difference in qual­ity of life? Am Surg. 2000;66(6):540–6.
S. H. Lai and J. D. Vogel
Rectal Prolapse: Rectopexy vs Perineal
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Proctosigmoidectomy
SarahA.Vogler andKristenA.Ban
Introduction
Surgical options to treat rectal prolapse include abdominal and perineal approaches. Abdominal approaches include resection, suture, and mesh rectopexy. Suture recto­pexy can be performed with or without resection of the sigmoid colon and employs an anterior, posterior, or circumferential mobilization of the rectum. Mesh recto­pexy is typically performed with a ventral or anterior dissection. Increasingly, abdominal repairs are performed with a minimally invasive laparoscopic or robotic approach. Perineal approaches to treat rectal prolapse include perineal proctosig­moidectomy, also known as the Altemeier procedure, as well as the Delorme procedure.
Historically, the abdominal approach was favored due to the lower risk of recur­rence, with the perineal approach reserved for high-risk surgical candidates includ­ing the elderly or those with signicant comorbidities. In recent decades, the incidence of abdominal surgeries has increased, while the number of perineal sur­geries has decreased. This is reective of minimally invasive surgical (MIS) tech­niques offering ease of tolerance, acceptable outcomes, and rapid recovery even for high-risk surgical candidates. Numerous factors impact procedure choice, including overall health of the patient, gender, prior surgical history, symptoms, and presence of concomitant prolapse in other pelvic compartments.
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S. A. Vogler (*) Cleveland Clinic Florida, Martin Health, Port St Lucie, FL, USA e-mail: voglers@ccf.org
K. A. Ban Cleveland Clinic Foundation, Cleveland, OH, USA e-mail: bank4@ccf.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery, Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_38
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S. A. Vogler and K. A. Ban
One challenge in assessing the surgical literature on rectal prolapse repair is the paucity of adequately powered level 1 data. Additionally, there is heterogeneity among studies comparing the abdominal versus perineal approach as within each category there are multiple surgical options. Kim etal. note that “the myriad of methods available to correct the underlying anatomic defects in complete rectal prolapse poses a perplexing question for the surgeon, i.e. the choice of an ideal operation.” [1] The objective of this review is to compare the various rectal prolapse repair surgeries and outcomes including morbidity, recurrence, functional, and quality of life.
Search Strategy
A search was performed using search terms dened by the PICO model outlined in Table38.1. The population of interest was patients with rectal prolapse undergoing rectopexy and the comparator was patients undergoing perineal proctosigmoidec­tomy. Outcomes of interest included recurrence of rectal prolapse, functional out­comes, quality of life, morbidity, and mortality.
PubMed was searched for relevant studies including systematic reviews (SR) and meta-analyses (MA). The following keywords were employed: “rectal prolapse”, “procidentia”, “rectopexy”, “perineal proctosigmoidectomy”, “perineal proctec­tomy”, “Altemeier”, “Delorme”. All articles identied during the initial search were screened. The references of relevant articles were reviewed to identify additional studies. Inclusion criteria for consideration included publication in English, adult (> age 18) human subjects, and a study population of more than 20 patients.
Table 38.1 PICO model
Patient Population Patients with rectal
prolapse
Intervention Comparator
Rectopexy
Perineal proctosigmoidectomy
Outcomes Recurrence Functional
outcomes Quality of life Morbidity Mortality
38 Rectal Prolapse: Rectopexy vs Perineal Proctosigmoidectomy
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Results
Abdominal Versus Perineal Approach
Data comparing outcomes after abdominal compared to perineal rectal prolapse repair come from four recent randomized trials and retrospective reviews of single­institution experiences.
The PROSPER trial was an international, multicenter, pragmatic, factorial study that randomized 293 patients to abdominal (suture vs. resection rectopexy) vs. peri­neal (Altemeier vs. Delorme) rectal prolapse procedures and controlled for age, ASA status and preoperative bowel function [2]. Median follow-up was 3years. A more recent multicenter, factorial randomized trial reported by Smedberg et al. recruited 134 patients who underwent the same four procedures [3]. Recurrence was determined at 3years. Both studies were underpowered and neither study included ventral mesh rectopexy (VMR). Deen etal. reported a randomized trial allocating 20 total patients to abdominal resection rectopexy and pelvic oor repair versus perineal proctosigmoidectomy with median follow-up of 17months [4]. Emile etal. randomized 50 patients to laparoscopic ventral mesh rectopexy versus Delorme with a median follow-up of 18 months [5]. A high percentage of patients were male (38%).
Kim etal. at the University of Minnesota reported one of the largest retrospective reviews over 19years of rectal prolapse repairs performed on 372 patients [1]. 183 underwent perineal proctosigmoidectomy, 161 underwent resection rectopexy, 11 underwent Delorme, and the remaining underwent partial colectomies or anterior resections. Patients who underwent perineal procedures were signicantly older and sicker and had shorter recurrence-free survival. A long-term retrospective review by Ng etal. in Australia evaluated 157 patients undergoing surgical prolapse repair, including 44 patients who underwent resection rectopexy, 38 who underwent recto­pexy, 55 who underwent Delorme, and 20 who underwent Altemeier with median follow-up of 4.5years [6]. Patients who underwent perineal procedures were sig­nicantly older with a mean age of 80 compared to 67years in the abdominal cohort (p=0.001). Hu etal. compared laparoscopic ventral mesh rectopexy and perineal repair specically in men with a median follow-up of 48.5months [7].
Morbidity
The PROSPER trial reported higher morbidity in the perineal group compared to the abdominal group [2]. Four mortalities were reported following perineal proce­dures, and one mortality was reported following an abdominal procedure. Four seri­ous morbidities were reported in the perineal group, all anastomotic leakages following Altemeier operations, and no serious morbidities were reported in the abdominal group. The 4-arm randomized trial reported by Smedberg described higher complications in the perineal group than the abdominal group (3 total versus none), but this difference was not signicant (p= 0.314) [3]. Hospital stay was
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signicantly longer in the abdominal versus perineal cohort (mean 8days versus 5days, p=0.022). Deen etal. reported higher morbidity in the resection rectopexy group with 2 ileus, one wound infection, and one anastomotic stricture [4]. Emile etal. reported no major morbidity or mortality in either group [5].
Kim etal. reported similar overall complication rates in the abdominal and peri­neal cohorts, though the complications differed in the two groups [1]. Small bowel obstruction was the most common complication after an abdominal procedure (21/176 patients), but was not reported in any patient undergoing a perineal proce­dure. Patients undergoing perineal procedures reported higher numbers of urinary, cardiac, and anastomotic complications than in the abdominal cohort. Ng et al. found that morbidity was higher in the perineal cohort (17.1%) compared to abdom­inal (10.7%), though the difference was not signicant [6]. The Altemeier procedure carried the highest morbidity (20%) followed by resection rectopexy (18%), recto­pexy alone (16%), and Delorme (7%). In the male study population described by Hu etal., no mortalities were reported, and complication rates were signicantly lower after ventral mesh rectopexy (0%) compared to perineal repair (20.7%) (p=0.031) [7].
S. A. Vogler and K. A. Ban
Recurrence
The PROSPER trial did not report any signicant differences in recurrence rates between abdominal versus perineal approaches or between different procedures in the same approach category [2]. Reported recurrence among randomized patients was 20% in the perineal group compared to 26% in the abdominal group (p=0.8). Reported recurrence for all patients, including those who did not undergo intended procedure, was 24% after Altemeier, 31% after Delorme, 13% after resection recto­pexy, and 26% after suture rectopexy. Smedberg etal. reported 3-year recurrence rates favoring the abdominal approach that were not signicant [3]. Recurrence after suture rectopexy was 21%, after resection rectopexy 10%, after Delorme 58%, and after Altemeier 50%. Deen etal. reported no recurrence after resection recto­pexy and one recurrence after Altemeier, which was not statistically signicant [4]. Emile etal. reported higher recurrence following Delorme (16%) compared to ven­tral mesh rectopexy (8%), but the difference was not signicant (p=0.66) [5]. None of the studies reported above were adequately powered to detect differences in recurrence.
Kim etal. reported signicantly lower recurrence after abdominal (5%) versus perineal (16%) procedures (p= 0.002) [1]. Ng et al. reported signicantly lower recurrence rates in their abdominal operation cohort and found that perineal versus abdominal surgical approach independently predicted recurrence in Cox regression analysis [6]. 5-year recurrence was highest after Delorme (52%), followed by Altemeier (30%), rectopexy (5%), and lowest after resection rectopexy (3%). Hu etal. reported signicantly lower recurrence in men following ventral mesh recto­pexy (9.5%) versus perineal repair (41.7%) (p=0.018) with median follow-up of
48.5months [7].
38 Rectal Prolapse: Rectopexy vs Perineal Proctosigmoidectomy
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Function andQuality ofLife
The PROSPER trial reported similar signicant functional and quality of life improvements following all procedures evaluated that were maintained at 3-year follow-up without signicant differences between groups [2]. Fecal incontinence measured by the Vaizey score, bowel function measured by the bowel thermometer, and quality of life measured by the EQ-5D all improved after surgery. Smedberg etal. reported improvements in Wexner and RAND-36 scores after all procedures without signicant differences between procedures [3]. In the perineal procedure cohort, Deen etal. reported signicantly higher residual fecal incontinence (FI) (OR
13.5) and signicantly lower maximum resting and squeeze pressures on manome­try (p=0.003) [4]. Constipation and global quality of life scores were not reported. Emile etal. reported similar postoperative improvement in bleeding, fecal inconti­nence, constipation, Wexner constipation and incontinence scores, Gastrointestinal Quality of Life Index (GIQoL), and Fecal Incontinence Quality of Life (FIQL) scores after both Delorme and ventral mesh rectopexy [5]. Improvements in anal manometry measurements were also similar in both groups.
Kim etal. reported similar improvement in fecal incontinence, constipation, and overall satisfaction following both abdominal and perineal procedures [1]. In a male population, Hu etal. reported only perineal repair signicantly improved constipa­tion (p=0.001) with an improvement from 72% preop to 25% postop [7]. No sexual dysfunction was reported in either group.
Robotic Versus Laparoscopic Abdominal Approach
The highest volume of literature comparing minimally invasive surgical approaches pertains to ventral mesh rectopexy. Four recent SRs and three MAs compare robotic and laparoscopic ventral mesh rectopexy outcomes. Bao etal. found 14 observational studies with over 750 patients assessing the safety and efcacy of laparoscopic and robotic ventral mesh rectopexy [8]. Follow-up was variable, from 1months to 5years. Operative time was longer in the robotic population, but hospital length of stay was shorter. All studies captured in the SR by Albayati etal. were included in the larger analysis by Bao and colleagues [9]. Emile etal. performed SR and MA of outcomes following laparoscopic ventral mesh rectopexy and performed meta-regression analy­sis of predictors of recurrence [10]. The MA included 17 studies and 1242 patients with a median follow-up of 23months. Flynn etal. found six studies meeting inclu­sion criteria [11], all of which were also included in the Bao SR and MA.In total, the studies included 382 patients with follow-up ranging from 1month to almost 5years.
Morbidity
Bao etal. in their MA reported fewer conversions to open in the robotic compared to laparoscopic populations, though this difference was not statistically signicant [8]. The robotic approach had a signicantly lower mean intraoperative blood loss
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(weighted mean difference −20.69, 95% CI −35.74 to −5.63, p=0.007). Robotic ventral mesh rectopexy had signicantly lower post-operative complications (OR
0.45, 95% CI 0.24–0.83, p= 0.009). The review by Emile etal. reported pooled outcomes after laparoscopic VMR, including a conversion to open rate of 1.8% and a complication rate of 12.4%, primarily driven by urinary tract infection, urinary retention, with rare reports of urethral injury, bladder injury, and vas deferens injury in male patients [10]. Mesh-related complications were reported in less than 1% of patients.
Flynn etal. reported no signicant difference in complications (pooled OR in favor of robotic surgery 0.74, 95% CI 0.35–1.56) or conversion to open (pooled OR
1.09, 95% CI 0.28–4.20) [11]. Robotic VMR had a trend toward longer operative times (pooled SMD 0.39 favoring laparoscopic, 95% CI −0.43–1.22) and signi­cantly shorter length of stay (pooled SMD −0.42, 95% CI −0.67–0.17).
S. A. Vogler and K. A. Ban
Recurrence
Bao et al. reported no statistically signicant difference recurrence between the robotic and laparoscopic populations, including after sensitivity analysis [8]. Follow-up in included studies ranged from 1month to 5years and in many cases was inadequate to capture recurrence except in cases of early technical failure. Emile etal. reported a weighted mean rate of recurrence of full thickness prolapse following laparoscopic VMR of 2.8% at a median follow-up of 23months [10]. Meta-regression analysis of factors signicantly associated with prolapse recur­rence included male gender (SE = 0.018, 95% CI 0.008–0.044, p = 0.008) and length of mesh (SE=−0.007, 95% CI −0.01 to −0.001, p = 0.025), with shorter mesh associated with recurrence.
Flynn etal. did not pool or compare recurrence rates for MA, however, a sum­mary of recurrence rates was similar between the two procedures and was overall very low, less than 10% after both procedures with follow-up ranging from 1month to 5years [11].
Function andQuality ofLife
In their MA, Bao etal. reported no statistically signicant difference in pre- and post-operative mean Wexner scores (weight mean difference 0.09, 95% CI
−0.63-0.82, p=0.79) [8]. The pooled laparoscopic cohort had a higher unadjusted rate of post-operative FI, but this difference was not signicant. In their SR, Emile etal. reported signicant improvement in pre- versus post-operative FI in majority of patients undergoing laparoscopic VMR [10]. The weighted mean rate of improve­ment in FI was 79.3% (95% CI 69.4–89.1, I2=87.8%), and the weighted mean rate of improvement in constipation was 71% (95% CI 55.2–86.9, I2=91.2%).
Flynn etal. noted that heterogeneity of functional outcome assessment scores prevented pooling of results [11]. Overall, both groups showed improvements in
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