Lap Ventral Rectopexy fo patients >80 years
LAPAROSCOPIC VENTRAL RECTOPEXY FOR EXTERNAL RECTAL PROLAPSE IS VERY SAFE IN THE ELDERLY, PERINEAL PROCEDURES ARE ALMOST OBSOLETE: TIME FOR RE-APPRAISAL OF A CLASSIC ALGORITHM.
Wijffels N, Cunningham C, Dixon A*, Greenslade G**, Lindsey I.
Pelvic Floor Centre, Churchill Hospital, Oxford and
Departments of Colorectal Surgery and Anaesthetics**, Frenchay Hospital, Bristol*
Address for correspondence
Introduction: Perineal procedures, despite high recurrence rates and poor resolution of incontinence, are generally recommended for external rectal prolapse in the elderly for safety. Abdominal rectopexy has lower recurrence but performed posteriorly frequently induces constipation. Laparoscopic ventral rectopexy (LVR) improves existing and avoids inducing new-onset constipation and its minimal invasiveness allows tolerability in the elderly. We aimed to assess results of laparoscopic ventral rectopexy in elderly patients with external rectal prolapse.
Methods: Data on LVR for patients over eighty with external rectal prolapse in two tertiary colorectal pelvic floor centres (Oxford and Bristol) were collected prospectively and analysed. End-points were mortality, morbidity, length of stay. A subgroup was analysed for change in bowel function (Wexner constipation score and Faecal Incontinence Severity Index).
Results: 80 patients (98% female, median age 84, range 80-97 years, mean ASA grade 2.44 [s.d. 0.57]) underwent LVR, 44 in Oxford and 36 in Bristol, 33 (41%) with recurrent rectal prolapse. 30-day mortality (0%), morbidity (11%), hospital stay (2 days) and recurrence (2%) was acceptably low.
Discussion: LVR combines the low morbidity of a perineal procedure with the low recurrence of an abdominal approach, without worsening or inducing new constipation. LVR can be offered to all fit patients with external rectal prolapse, regardless of age, perineal procedures should be restricted to the very frail and are thus almost obsolete. The classical algorithm for treatment of external rectal prolapse needs reappraisal.
More recently, autonomic nerve-sparing anterior or ventral rectopexy has been shown to be a further advance. D’Hoore et al has described laparoscopic ventral mesh rectopexy (LVR) treating 109 consecutive patients with external rectal prolapse 21,22. By creating a pocket at the level of the rectovaginal septum, ventrally to the rectal wall, dissection is kept at a minimum. Apart from avoiding classical posterior rectal dissection and rectal denervation by sparing the lateral ligaments, morbidity is shown to be low. The reproducibility of these excellent results with this technique has been shown by ourselves23,24
The primary aim of this study was to evaluate mortality and morbidity in elderly patients with full thickness external rectal prolapse, a group traditionally managed by perineal approaches.. Secondary aims were to assess length of hospital stay and rate of recurrent full-thickness external rectal prolapse. We aimed to compare the primary and secondary outcome measures to those published in perineal procedures for rectal prolapse.
Between January 2002 and December 2008, 80 patients with a full thickness external rectal prolapse 80 years of age or older, were operated on in two different centres with tertiary referral pelvic floor expertise (Churchill Hospital, Oxford and Frenchay Hospital, Bristol). The diagnosis of full-thickness external rectal prolapse was made clinically, or when suspected, confirmed on defaecation proctography. Patients underwent preoperative colonoscopy or flexible sigmoidoscopy to exclude organic disease.
The technique of LVR has been well described21,22,23. Peri-operatively prophylactic iv-antibiotics are administered, either a combination Co-amoxiclav or Gentamicin and Metronidazole. The patients are positioned in Lloyd-Davies with hip flexion. A 30-degree laparoscope is placed in the umbilical tube. Right iliac fossa 10mm and 5mm operating ports are inserted; a 5mm suprapubic port is optional. If present, the uterus is either hitched to the anterior abdominal wall using 2/0 silk on a straight needle or elevated by a Spakman retractor. A superficial peritoneal window is made using a hook dissector with monopolar diathermy to the right of the sacral promontory and extended caudally over the right outer border of the mesorectum down towards the right side of the deep Douglas pouch. This approach spares the right hypogastric nerve (deeper), ureter (more lateral) and avoids mobilisation of the mesorectum. At the deepest point of the right Douglas pouch the longitudinal incision is terminated. The peritoneum, posterior to the apex of the rectovaginal septum is grasped and retracted postero-cranially. A narrow Deaver retractor (or the Spakman retractor) placed in the vagina is retracted antero-caudally, with a force equal and opposite to the former. The areolar plane of the recto-vaginal septum opens with the first transverse peritoneal incision overlying the apex of the septum. A purely anterior rectal dissection is then undertaken in this areolar layer down to the pelvic floor (figure 1), the distal limit confirmed by digital rectal and vaginal examination.
A 3 x 20 cm strip of polypropylene or polyester mesh is introduced and positioned and sutured as distally as possible on the anterior rectum/perineal body. The mesh is sutured to the anterior wall of the rectum with interrupted non-resorbable sutures (Ethibond® Excel 00, Ethicon, Edingurgh, UK); the vaginal posterior wall is fixed with the same sutures and so creates a new rectovaginal septum. The mesh is secured to the sacral promontory using three Protack staples (Autosuture, Tyco Healthcare, Gosport, UK). If the vaginal wall is not fixed as described, the vaginal vault (or cervix) is fixed to the mesh without traction by two additional sutures. The mesh is then peritonealised by suturing the free edges of the previously divided peritoneum over the mesh with the same suture or 2-0 Vicryl (Ethicon, Edinburgh, UK); provides additional ventral elevation and avoids small bowel adhesion to the mesh.
General Anaesthesia is used with short acting opioids, intravenous propofol or inhalation agents. Administration of significant amounts of intravenous fluids is avoided. Apart from short acting opioids pain is controlled with intravenous paracetamol often combined with a transversus abdominal plane block (TAP block)54.
Data and statistical analysis
Data on gender, age, ASA classification, mortality, morbidity, length of stay and recurrence were prospectively collected on a institutionally approved electronic database. Non-parametric data were described as median and range and parametric data as average and standard deviation.
Between January 2002 and December 2008, 80 patients (median age 84 years, range 80-97 years), underwent LVR (figure 2). Average ASA grade 2.44 (sd +/- 0.57); I (2), II (42), III (35), IV (1). Seventy-eight (98%) were female. Thirty-six patients were operated in Bristol and 44 in Oxford. In the same period, four patients underwent perineal procedures. One Delorme’s procedure was performed on a demented elderly lady unconcerned about bowel function. One patient underwent Delorme’s preferentially because of fixed flexure contractions and two patients did so by surgeons other than the authors untrained in LVR.
Thirty-three patients were operated on for a recurrent rectal prolapse (28 Delorme’s procedure between 1 and 12 years earlier, 2 posterior rectopexy between 4 months and 9 years earlier, and 1 Altemeier’s resection). Eight patients (10%) had undergone two or more interventions.
Morbidity and Mortality
There was one (1%) major complication (inferior on-table myocardial infarction successfully paced) and 12 minor complications in 9 patients (11%) (table 1 & 2). There was no mortality. The most common complications were chest infection, port-site hernia and urinary tract infection. There were no mesh related complications i.e., infection, erosion or migration. There was one conversion (1%) for widespread abdominal and pelvic adhesions following a previous hysterectomy and a failed complicated open posterior rectopexy. A Pfannenstiel incision was utilised to take down the adhesions before closing and completing the LVR laparoscopically. This was complicated by wound infection for which the patient was readmitted.
Length of stay and recurrence
The median length of stay was 3 days (range 1-37 days). The median follow-up was 23 months (range 2-82 months). Six patients (all died from unrelated causes) were lost to follow-up. Two demented patients were discharged from follow-up at 6 months. Two (3%) patients developed a recurrent full thickness prolapse at 6 and 16 months. Both were re-operated, 1 by redo-LVR and the other by Delorme’s procedure. Three patients developed symptomatic recurrent/persistent mucosal prolapse, treated with an anopexy (2) and with a STARR procedure (1).
Perineal procedures have traditionally been considered the “gold standard” treatment of a full-thickness external rectal prolapse in elderly patients with often high co-morbidities where an invasive laparotomy is avoided. This does not mean however, that perineal procedures are without risk. Delorme’s rectal-mucosectomy has a morbidity of 12-14% and mortality 0-5% 3,25-35. Altemeier’s perineal rectosigmoidectomy has a similar risk of death (0-6%) and an even higher morbidity (5–25%)36-52. Whilst an Altemeier’s resection has better functional results than Delorme’s there is always a risk of an anastomotic leak.
Since its advent, laparoscopic surgery is gaining rapid popularity and momentum. A recent Cochrane Collaboration review concluded that laparoscopic rectopexy results in fewer postoperative complications and an earlier discharge53 over open methods. Other outcomes were similar in the open and laparoscopic groups, which imply that the advantages of abdominal approach apply to laparoscopic surgery. Although laparoscopic rectopexy has become popular it has as yet not been advocated in the “super elderly” who perhaps might be considered at increased risk from this approach.
Our experience would suggest that the laparoscopic approach needs re-evaluating. In this sizeable consecutive series of “super elderly” patients with full-thickness rectal prolapse there were no deaths and morbidity was very low with only one major complication, proof that LVR is a safe alternative. It is also very predictable with good functional outcomes 26,27,28 LVR despite its minimal dissection also has a very low recurrent prolapse rate compared to the 25-30% seen with perineal procedures5. D’Hoore reported that in a subgroup of 42 patients with a 5yr follow-up the recurrence rate was only 5% (2 patients). Our 3 % recurrence rate after a median 23-month follow-up is consistent with this figure.
A 30-degree laparoscope allows the surgeon to dissect the rectovaginal plane all the way down to the perineal body and the muscles of the pelvic floor (figure 1). The extent of this dissection can be checked during the procedure by performing a digital vaginal/rectal examination against an endoscopic instrument placed at the distal end of the dissection plane as a reference. We believe that a good fixation of the mesh to the ventral rectal wall, as distal (or caudal) as possible, is essential to minimize the risk of recurrence.
Although the ability to control a full thickness rectal prolapse with good functional results seem to be reproducible, it is very important to realise that the procedure does come with a learning curve. This particularly applies to the sometimes difficult distal fixation of the mesh to the anterior rectal wall. Our two recurrences occurred in the first 12 patients operated in Oxford.
In our two clinics LVR is offered to every patient despite their ASA grade. It must be stated that operating on these sometimes frail, elderly patients necessitates good anaesthetic care. Concerns regarding patients with moderate COPD developing pneumothorax have proven to be somewhat overstated, possibly because the lungs are splinted by the pneumoperitoneum, resulting in the transmural pressure difference being smaller than might otherwise be the case. The cardiac patients most likely to die suddenly at induction of anaesthesia mostly have aortic stenosis. Here, a drop in systemic vascular resistance can quickly translate into inadequate coronary artery perfusion as the diastolic arterial pressure falls. The same is true—to a lesser extent—in patients with ischaemic heart disease. With laparoscopic surgery in our institutions, the anaesthetist manages the patient’s cardiac afterload mostly by the administration of drugs such as the short acting opioids, intravenous propofol or inhalational agents. Elderly patients seem to tolerate laparoscopic surgery remarkably well, provided they are not in left ventricular failure. Using short acting agents and avoiding administration of significant amounts of intravenous fluids allows quick recovery to their pre-operative state within minutes of the end of surgery.
Many colorectal surgeons will state that a perineal approach is much better tolerated than a transabdominal approach but anaesthesia used in perineal procedures such as a Delorme’s or Altemeier’s procedure has its disadvantages. Many surgeons require the patient to be positioned prone for this operation. This position is associated with unpredictable circulatory changes that may require the surgeon to abandon the operation to that the patient can be put onto his or her back to allow correction of the circulation, which can rapidly worsen in patients with a tendency toward heart failure. Airway pressures, when ventilating the lungs of a patient in a prone position, are often very similar to those seen during well-conducted laparoscopic surgery, except that there is no pneumoperitoneum to splint the alveoli, resulting in higher trasnsmural pressure differences in the alveoli, because there is no pneumoperitoneum to splint them. Spinal anaesthesia is only practicable when the patient can be operated upon in the lithotomy position. Putting the patient prone soon after a spinal injection of local anaesthetic could lead to extensive spread of the local anaesthetic, with sympatholytic activity accompanying that spread. The anaesthetist then has to respond with vasopressors and fluid boluses during surgery, leaving the patient to sort out the physiology when the spinal anaesthetic wears off.
Out of 84 patients with ERP, none were treated conservatively. 80 were offered a LVR and of the remaining 4 patients, one was considered laparoscopically inoperable because of fixed flexure contractions. Another was demented and unconcerned about bowel function but in retrospect could have been offered LVR. The other two were operated by surgeons not familiar with LVR and could have been operated by LVR. ASA grade or co-morbidity was not a decisive factor in deciding what technique to use.
LVR combines the advantages of laparoscopy (shorter hospital stay, quicker patient recovery, lower costs and less morbidity), a trans-abdominal approach (reliable improvement in incontinence, low recurrence rate) and an anterior rectal dissection (autonomic nerve-sparing, improves constipation, avoids inducing new-onset constipation). LVR is tolerated very well in the elderly, allowing avoidance of the compromise of a perineal procedure (trade-off of safety for high recurrence and unreliable resolution of incontinence). We believe that this makes perineal procedure indicated rarely only in the very frail, and thus almost obsolete. The classical algorithm of abdominal procedure if young / perineal procedure if old should be abandoned, especially as the population is increasingly ageing.
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Colorectal Dis. 2009 Jan 16. [Epub ahead of print]