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_1705_Библиотеки_им_академика_М_И_Перельмана.pdf
287
The subsequent Swedish rectal prolapse trial shared similar dif-
culties in patient accrual and showed similar results after a median
follow-up of 2.6years both in terms of improved bowel function
scores and high prolapse recurrence rates, which were not signi-
cantly different when comparing different surgical procedures. At
least 20 percent of the recurrences occurred later than 3years after
surgery [1]. One of the limitations of both the PROSPER and the
Swedish rectal prolapse trial is that anterior rectopexy was not
among the procedures analyzed. This is a more recently intro-
duced technique which especially when using minimally invasive
approaches could be associated with improvement in functional
results and reduced rates of prolapse recurrence when compared
to the abdominal and perineal procedures analyzed in those trials.
The NORDIC rectal prolapse study will evaluate laparoscopic
ventral mesh rectopexy as the preferred operation which will be
compared in a noninferiority study design to other well-estab-
lished procedures for rectal prolapse [2]. A network meta-analysis
based on nine randomized controlled trials indicated that poste-
rior mesh rectopexy had signicantly lower odds of recurrence
than did the Altemeier procedure, Delorme procedure, resection
rectopexy, sponge rectopexy, and sutured rectopexy, but similar
odds to ventral mesh rectopexy [3]. At this time, there is no statis-
tically signicant data from individual randomized trials indicat-
ing a specic surgical procedure which should be viewed as the
most preferable standard of care. In the absence of denitive sci-
entic data, most surgeons probably agree that an abdominal
repair is associated with a decreased risk of prolapse recurrence
when compared to a perineal approach, which should be generally
reserved for high-risk patients.
References
1. Smedberg J, Graf W, Pekkari K, Hjern F.Comparison of four
surgical approaches for rectal prolapse: multicentre random-
ized clinical trial. BJS Open. 2022;6(1):zrab140. https://doi.
org/10.1093/bjsopen/zrab140.
2. Bach-Nielsen A, Christensen P, Cornish J, etal. The NORDIC
rectal prolapse study: a multicenter international cohort study.
Colorectal Dis. 2023;25(S2):239–40.
References
288
3. Emile SH, Khan SM, Garoufalia Z, et al. A network meta-
analysis of surgical treatments of complete rectal prolapse.
Tech Coloproctol. 2023;27(10):787–97.
Discussion
DC
They make the point that this was the largest trial at the time, in
2013, and indeed, nding 293 surgical patients with rectal pro-
lapse is no small feat. I think the intention was good. It was hard
(and in some ways, it still is) to know what to do with a patient
with rectal prolapse when all nonoperative measures have failed
or they are not a candidate for nonoperative measures. Which sur-
gery is best, and in what patient? I think this was the general ques-
tion they were looking at in a general sense. Denitely, the trial
design was the Achilles heel of this study. Yes, 293 patients
entered the study, but Fig.2 is very telling; on one hand, the pro-
cedure (abdominal vs perineal) was randomized in 49 patients,
and on another, the decision to randomize was made after the
decision was already made to proceed abdominally or perineally,
where the perineal approach was much more likely to be favored
(2.7 times more likely). So ultimately there was randomization,
but the way it was done and also the small (and multiple) group
sizes made it tough to detect a difference if there would have been
one. As an aside, I think that the perineal group is probably too
big, and it is likely that more people than strictly necessary are
having the Altemeier procedure, knowing that the recurrence rate
is higher than with an abdominal approach.
MD
I think it sounds like the Delorme procedure is much more popu-
lar in the UK because it seemed that they do more of that rather
than Altemeier. I was very surprised to see that there was no dif-
ference between Delorme and Altemeier procedures with regard
40 Comparison ofSurgical Treatments forRectal Prolapse
289
to recurrence because anecdotally, and I think in other studies,
perhaps where there is less experience with the Delorme proce-
dure, the recurrence is usually higher with the Delorme. I was
also very surprised to see that they did not show any difference
between abdominal versus perineal procedures with regard to
recurrence because other studies or meta-analyses looking at a
conglomerate of randomized trials have shown more so that
recurrence is less with abdominal operations. I think in this trial
the original plan was to recruit 900 patients, and 300 is quite
commendable, but I do not think that the study is necessarily
powered enough to nd the differences that they initially were
looking for. And the other thing was that they talked about bowel
function using the score between patients, but not of other things
that affect the recurrence of prolapse, like concomitant vaginal
prolapse, the degree of the prolapse, etc., factors which I think
signicantly affect recurrence for these patients. And the last
thing that has been gaining more traction now is ventral mesh
rectopexy and whether or not that is a better repair than a poste-
rior approach. Another aspect is not having robotic surgery. I
think that now with robotic surgery, the dissection can be visual-
ized more clearly, and perhaps, a more distal dissection is facili-
tated. Whether or not that makes a difference with regard to
abdominal operations, I think, is still unknown, but overall, I
think this was a large study for a patient population that is, in
general, hard to study and hard to recruit.
LS
I think that if you look at all the abdominal procedures combined
vs. all the perineal procedures combined, there is a difference, but
it does not reach statistical signicance. And I do believe that it is
because the study is underpowered to detect that. Some patients
have complex pelvic oor prolapse to be repaired at the same time
especially in centers specialized in pelvic oor disease, which
might require a perineal repair, as Michelle was alluding to.
Personally, I try very hard to do an abdominal repair unless there
are specic circumstances. For example, the prolapse is short or in
Discussion
290
case of an urgent operation for ischemic rectal prolapse. I try to
avoid a perineal procedure as much as possible. And I think that
the bar has shifted in terms of the denition of high risk, and there
are a lot of patients who used to be dened as high risk who are
actually capable of tolerating an abdominal procedure and there-
fore achieving the advantages of a reduced recurrence rate. In
addition, I would offer resection rectopexy, which is one of the
procedures included in the randomization, only in case of pro-
lapse associated with constipation, which I rarely see. Perhaps,
with the advent of ventral rectopexy, which has been proposed
also for rectal prolapse associated with constipation, this will
become even less common.
I commend the investigators of this trial, and I noted that the
subsequent Swedish rectal prolapse trial was similar and was
faced with the same patient accrual challenges. PROSPER’s fac-
torial design did not help in obtaining a result which was statisti-
cally signicant. But this is the best science that we have, and
hopefully, newer trials will incorporate ventral rectopexy so that
we can have more denitive results.
40 Comparison ofSurgical Treatments forRectal Prolapse
291
© The Editor(s) (if applicable) and The Author(s), under exclusive
license to Springer Nature Switzerland AG 2025
D. Colibaseanu et al., Essential Articles in Colorectal Surgery,
https://doi.org/10.1007/978-3-031-77745-5
A
Abdominal mesh material, 216
Abdominoperineal resection, 205
ACOSOC Z6051, 122
ACOSOG trial, 125, 201, 202
ACOSOG z6041 trial, 172
Adalimumab, 16
Adjuvant chemotherapy, 158
Air leak testing, 258–263
Altemeier procedure, 286
Alvimopan, 222
Anal stulas
LIFT, 242–247
Anal verge and anastomotic leak,
62–66
Anastomotic leak, 111, 112, 204
Anorectal cuff, 49
Anterior resection, 58
Anti-TNFα management, 25–33
B
Bowel obstruction, 151
C
Canadian and American Surgical
Crohn’s disease Trial
(CAST), 8
Cedars Sinai group, 243
Chemoradiotherapy-consolidation
chemotherapy (CRT-
CNCT), 92, 93
Clinical complete response (cCR),
92, 93
CO
2
embolism, 204
Colon cancer
laparoscopic vs. open colectomy,
142–147
neoadjuvant chemotherapy,
150–156
stage IV, 166–170
Colonic obstruction, 58
Colorectal anastomoses, 272–275
CO
2
pressure, 259
Corticosteroids, 16
COST trial, 143, 147
Crohn’s disease (CD), 16
anti-TNFα management, 25–33
ECF, 214
handsewn vs. stapled ileocolic
anastomosis, 8–14
IPAA, 42, 43, 48
LIFT, 242
risk factors, 2–5
TNFα inhibitors and surgery,
16–22
Index
292
D
Data Monitoring and Safety
Board, 229
Defecatory function, 205
Defunctioning ileostomy, 215
Defunctioning stoma, 111, 113
Delorme’s procedure, 286, 288
Deloyers procedure, 273
Diabetes, 16
Diet, 220
DILALA trial, 229
Disease-free survival, 103, 151, 189
Diverting jejunostomy, 215
Diverting loop ileostomy, 110–118
Doctor and patient perception,
278–283
Dutch trial, 80, 81
Dysplasia, 37, 279
E
Endorectal ultrasound (ERUS), 250,
251
Enhanced recovery after surgery
(ERAS), 220–225
Enhanced recovery protocols (ERP),
220–225
Enterocutaneous stula (ECF),
214–218
European CAIRO4 trial, 167
F
Foley catheters, 220
FOLFOX group, 86
FOxTROT trial, 145, 151
G
Gastrogran aspiration risk, 267
H
Handsewn anastomosis, 8–14
Handsewn ileal pouch-anal
anastomosis, 36–40
Hypertension, 16
Hyperthermic intraperitoneal
chemotherapy (HIPEC),
162, 163
I
Ileal pouch anal anastomosis (IPAA)
Crohn’s disease, 42–45
revisionary surgery, 48–52
stapled vs. Handsewn, 36–40
Ileocolic resection, 28
Immunosuppressants, 28
Immunotherapy, 130–134
Induction chemotherapy-
chemoradiotherapy
(INCT-CRT), 92, 93
Inammatory bowel disease (IBD),
16, 18, 25, 28, 279
Iniximab, 16, 25–26, 30, 33
Intrabdominal adhesions, 214
Intravenous uid
rehydration, 266
J
JAMA publication, 122
Japanese JCOG 1007 trial, 167
K
Kono-S anastomosis, 9
Kono-S ileocolic anastomosis, 9
L
Laparoscopic lavage, 228–233
LAR, 121
Lateral lymph nodes, 187–193
Ligation of the intersphincteric tract
(LIFT), 242–247
Local excision (LE), 172–177
Index
293
Locally advanced colon cancer
neoadjuvant chemotherapy,
150–156
Locally advanced rectal cancer,
130–134
Locally recurrent colon cancer
surgery for, 158–163
Locally recurrent rectal cancer,
136–140
Local recurrence, 189
Loco-regional anesthesia, 221
Loco-regional metastasis, 54
LOLA trial, 230
Long-course radiotherapy, 102–107
Low anterior resection, 58, 62–66,
111
Lynch Syndrome, 130
M
Malnutrition, 17, 19
Mannheim Peritonitis Index score,
229
Mesorectal envelope, 54
Mesorectal excision, 187
Mesorectal fascia, 55
Mesorectal lymph nodes, 172
Mesorectum, 54
Minimally invasive surgery, 49, 142,
143
Mismatch repair decient (MMR-
D), 130–132
Mucosal advancement ap, 242
Mucosectomy, 36, 37
Multidisciplinary team (MDT), 250
Multivariate analysis, 16, 215
N
Nasogastric tube decompression,
266
Neoadjuvant chemotherapy, 87,
150–156
Neoadjuvant radiotherapy, 80
Neoplasia, 37
Non-inferiority studies, 121–123,
142, 145, 146
Non stricturing disease, 32
NORDIC rectal prolapse study, 287
O
Obstipation, 266
Obturator lymph nodes, 188
OPRA trial, 93, 95
Organ preservation, 92–99
Overall survival (OS), 136
Over-the-scope closure (OTSC),
216
P
Pain control, 220
Patient-controlled anesthesia, 221
Patient motivation, 48
PelvEx collaborative, 136, 139
Pelvic radiotherapy, 272
Pelvic sepsis/pouch-vaginal stula,
49
Pembrolizumab, 130, 131
Peripherally inserted central catheter
(PICC), 215
Primary anastomosis, 28
PRODIGE 22 trial, 151
Programmed death 1 (PD-1)
inhibitor, 130–132
PROlapse Surgery PErineal or
Rectopexy (PROSPER)
study, 286, 287
PROSPECT trial, 86, 87
PUCCINI trial, 17, 19
Q
Quality of life, 25, 26, 31
Index
294
R
RAPIDO trial, 103–106
Reconstructive surgery, 272–275
Rectal adenocarcinoma, 110
Rectal cancer(s)
diverting loop ileostomy,
110–118
doctor and patient perception,
278–283
immunotherapy, 130–134
laparoscopic vs. open
proctectomy, 121–127
lateral lymph nodes, 187–193
local excision, 172–177
locally recurrent, 136–140
magnetic resonance imaging,
68–71
preoperative radiotherapy and
surgery, 80–84
preoperative vs. postoperative
chemoradiotherapy,
74–78
radiotherapy, 86–90
robotic surgery, 196–202
short course vs. long course
radiotherapy, 102, 103,
105–107
sigmoid and high, 58–60
taTME, 204–212
TME, 53–56
total neoadjuvant treatment and
organ preservation, 92–99
Rectal lesions, TAMIS, 180–184
Rectal polyp, 250–255
Rectal prolapse, 286–290
surgical treatments, 286–290
Remicade, 29
Retroileal anastomosis, 273
Robotic vs. Laparoscopic Resection
for Rectal Cancer
(ROLARR) trial,
196–198, 201
ROLARR trial, 125
S
Short-course radiotherapy, 102–107
Sigmoid diverticular
disease, 236
Sigmoid diverticulitis
laparoscopic lavage, 228–233
laparoscopic vs. open surgery,
236–240
Small-bowel obstruction
surgical management, 266–270
Smoking, 16
Soave procedure, 273
Stapled ileal pouch-anal
anastomosis, 36–40
Stapled ileocolic anastomosis, 8–14
Steroids, 16
Stricturing disease, 32, 33
Surgical site infections
(SSIs), 16, 17
SYNCHRONOUS trial, 167
T
Terminal ileal disease, 25, 26
Total mesorectal excision (TME),
53–56, 59, 80, 122, 187
Total neoadjuvant therapy (TNT),
70, 87–90, 92–99, 102
Total parenteral nutrition
(TPN), 214
Toupet procedure, 273
Transanal endoscopic microsurgery
(TEM), 180
Transanal minimally invasive
surgery (TAMIS),
180–184
Transanal total mesorectal excision
(taTME), 204–212
Tumor necrosis factor inhibitors
(TNFi), 16–22
Tumor recurrence, 143
Tunneled central venous
catheter, 215
Index
295
U
Ulcerative colitis, 36–40
Urethral injuries, 204, 207
V
Vicryl mesh, 216
W
Watch and wait (WW) protocol,
92–94
Wound recurrences, 143
Index