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LVMR for external rectal prolapse: long-term results

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03/03/2014

Outcomes of Laparoscopic Ventral Mesh Rectopexy for External Prolapse

J Randall, E Smyth, AR Dixon

North Bristol & SPIRE Hospitals Bristol 

 

ABSTRACT

Aim: To assess the efficacy of laparoscopic ventral mesh rectopexy (LVMR) for full thickness external rectal prolapse, including recurrent rectal prolapse.

Methods: A prospective database was used to identify all patients who underwent LVMR for external prolapse over the sixteen year period to December 2013.

Results: 190 patients (87 % female), median age 69 years (18-93) underwent LVMR; median active follow up was 29 months (1-196) and median time from operation was 73 months (1- 196). 120 patients were operated on >5 years and 16 >10 years from the end of the study period. The 60-day mortality was 1%, the recurrence rate was 3% with a current mesh erosion rate of 3.6%. Cleveland Clinic incontinence scores improved by a median of 8 points (P<0.0001). 62 patients returned a complete sequence of QoL scores (Birmingham Bowel and Urinary Symptoms Questionnaire-22), which improved by 46% at 1 year. This improvement was sustained at a median of 4 years (P<0.001). Mean patient reported satisfaction at final review was 9.1 out of 10.  39 patients underwent a LVMR for recurrent prolapse post perineal repair(s). Full thickness recurrence was seen in one and there were no mesh complications. The same improvement in QoL was seen in this subgroup.

Conclusion: LVMR can be performed for external rectal prolapse, including those who’ve had previous failed perineal procedures, with low recurrence rates and morbidity. LVMR produces long term functional benefits and results in sustained improvements in QoL.

 

 

 

 

Introduction

A variety of surgical techniques are available for repair of full thickness external rectal prolapse. The recently reported PROSPER trial found no significant differences in outcome between those undergoing a perineal or an abdominal procedure, and those undergoing suture or resection rectopexy. However the authors noted particular difficulty in recruiting to randomising between abdominal and perineal approaches and whilst significant improvements in quality of life were seen in all procedures, a high rate of recurrence was identified. [Senapati 2013](1).

Laparoscopic ventral mesh rectopexy (LVMR) is a well-recognised procedure for treatment of external prolapse in adults with low morbidity and low rates of morbidity and early recurrence [D’Hoore 2004, Slavik 2008] (2,3). The procedure is safe in elderly patients [Wijffels2011] (4). Limiting dissection to the anterior rectum with an autonomic nerve sparing technique is also believed to limit postoperative constipation [Boons 2010] (5).

The aim of this study was to assess the efficacy of LVMR for full thickness external rectal prolapse. Of particular interest are those patients with longer term follow up and those with recurrent rectal prolapse, having undergone a previous failed Delorme’s or Altemeier perineal repair.

 

Methods

Patients who underwent LVMR for external rectal prolapse in a single institution were identified from a prospectively updated database. The study period was sixteen years from January 1997 to December 2013. The series includes referrals of challenging or recurrent cases received from other institutions.

Demographics, symptoms including continence, obstructive defecation and dyspareunia, as well as any previous procedures were recorded. Patients were asked to complete Cleveland Clinic faecal incontinence (FI) scores and a quality of life (QoL) score (Birmingham Bowel and Urinary Symptoms Questionnaire-22). Selected patients underwent pre-operative investigations including dynamic defaecography, transit studies and anorectal physiology as appropriate.

 

Most patients were admitted on the day of surgery and length of stay was recorded as the time to leaving hospital. After an initial examination of the anorectum under anaesthetic, a laparoscopy was performed using a 10mm 15-degree camera and two additional ports. Ventral mesh rectopexy was performed as previously described (Badrek Al-Amoudi 2013) (6). Posterior dissection was avoided in most cases. During the series there was a move from polypropelene to polyester meshes and then to titanium coated lightweight polypropylene mesh. There was also a move to a longer (20cm) mesh.

Active follow up was at 6, 12 and 26 weeks and annually thereafter. Patients were asked about new or persistent symptoms and the effect of the operation on their sexual function. Overall satisfaction with the procedure was established through a simple scale of 0 (not satisfied) to 10 (very satisfied). Patients were asked to complete FI and QoL scores post-operatively and at yearly intervals afterwards.  Many patients were discharged as their symptoms settled but returned if there was a problem. Outcomes related to complications can therefore be considered to have follow up to the end of the study. All further operations were recorded, including the need and timing of re-do surgery. Complications of the primary or re-do surgery including re-admissions and mesh-related complications were documented. All full thickness recurrences were recorded. Where this diagnosis was not obvious from history and examination, dynamic defaecography was repeated and/or examination under anaesthetic.

Data was analysed as intention to treat on a last observation carried forward basis. This was necessary to allow meaningful comparisons between the patient groups. Only those who returned a complete set of baseline and follow up QoL scores were included in the final analysis. After analysis of the entire group, a further analysis was performed on those with longer term follow up (>5 years) and those operated on for recurrent prolapse.

 

Statistics

The quality of life data was deemed to be non parametric and analysed accordingly. SPSS version 18 was used for statistical analyses. A Wilcoxon signed rank test was used for comparison of the groups and a value of p<0.05 was deemed to be consistent with a statistically significant result. A separate sub group analysis was performed for those patients who presented with recurrent rectal prolapsed. This data was analysed using a Kruskal Wallis test, again a value of p<0.05 was deemed to be consistent with a statistically significant result.

 

Results

From January 1997 to December 2013 190 patients underwent LVMR in a single institution for external rectal prolapse. The median patient age was 69 years (18-93) with a median active follow up of 29 months (1-196) and a median time of 73 months (1- 196) from the operation. The demographics of the group are shown in table 1.

All patients underwent examination under anaesthetic at the start and end of the procedure. As shown in table 2, 22 patients had an additional element to their procedure combined with LVMR, including a limited posterior rectal dissection (Orr-Loygue), anterior colporraphy, a posterior stapled transanal rectal resection procedure (STARR) or procedure for prolapsed haemorrhoids (PPH). Conversion from a totally laparoscopic case occurred in 5 cases, due to adhesions and difficult access. Median length of stay was 2.2 days (0-45); 51% had a 24 hour stay (table 2).

Complications

There were 12 re-admissions; medical and surgical complications are listed in table 2. Laparotomy was required for surgical-related complications in three patients: adhesional small bowel obstruction, perforated diverticular disease and a delayed enterotomy. The latter two patients died on days 6 and 8 respectively.

 

The current mesh erosion rate is 3.6%. Over half the mesh erosions seen were into the vagina, the remainder involving the rectum or a recto-vaginal fistula. Table 3 records the further procedures that patients in this series underwent. Of the mesh erosions, 3 went on to have local mesh excision and 3 laparoscopic removal. Redo LVMR was performed after mesh removal. 1 patient eventually required a proctectomy for recurrent prolapse (LVMR performed for prolapsed rectal stump).

Recurrence

Six patients developed full thickness recurrence during the follow up period, giving an overall recurrence rate of 3%. Redo LVMR was performed for recurrence (table 3). Four further patients developed symptomatic posterior lateral intussusception, which was managed by the addition of a posterior STARR.

Patient reported outcomes, Faecal Incontinence (FI) and QoL scores

Mean patient reported satisfaction at last follow up, obtained from 119 patients, was 9.1 out of 10 (1-10). FI scores improved from baseline by a median of 8 points (0-16) (P<0.0001) at last follow up. This was a 93% improvement rendering subjects continent. As shown in table 3 only 14 patients (7%) needed further biofeedback after LVMR. QoL scores (BBUSQ-22) were assessed at baseline, 1 year and up to 5 years. 62 patients returned a complete sequence of QoL scores, which improved by 46% at 1 year. This improvement was sustained at last follow up, median 4 years (P<0.001).

Sexual function

Pre-operatively 9 patients described dyspareunia as a significant symptom. Whilst this resolved in all cases, two patients (1%) developed new onset dyspareunia. There were no cases of hyspareunia and none of the male patients developed new-onset impotence or retrograde ejaculation.   44% of 169 patients who responded to questions addressed at their sexuality were not sexually active post-operatively. 37% felt that their sex life was improved, 16% felt there had been no change, whilst 2% described a worsening of their sex lives.

 

 

 

Longer term follow up group

120 patients were operated on more than 5 years from the end of the study period and 16 over 10 years. 4 patients (3.3%) returned with recurrence in this group at 25, 30, 31 and 60 months. Nine patients died from other causes, without their prolapse recurring, at a median of 6 years post- surgery (0.5-8).

 

Recurrent prolapse group

39 patients had a LVMR performed for recurrent prolapse after a previous perineal repair, including repeated perineal procedures as shown (table 1). Length of stay in this group was a median of 2 days (1-5) and active follow up a median of 27 months (1- 184). Complications included the mortality occurring at day eight following re-operation for a delayed presentation of an enterotomy on day seven described above. There were no re-admissions or mesh complications.

 

One patient (2.5%) developed a full thickness external recurrence whilst another a partial thickness posterior prolapse during follow up. These were successfully managed by revision surgery- the former patient’s mesh was reattached to the sacral promontory and a posterior suture Orr-Loygue rectopexy performed for correction of the posterior prolapse. The only other additional treatment required by this group was one patient requiring a period of biofeedback.

 

Overall patient reported satisfaction was 8.9/10. . Comparison of quality of life data (BBUSQ-22) between those patients undergoing revision procedures and those undergoing primary VMR showed no statistical difference between the two groups (p=0.459), highlighting that there is no significant impairment in outcomes.

 

 

Discussion

Controversy still exists over the optimum surgical approach to rectal prolapse. Many procedures are associated with potentially high recurrence rates. The recently reported PROSPER trial randomised more patients between perineal approaches than to abdominal rectopexy but described 3-year recurrence rates of 24% for Altemeier’s and 31% for Delorme’s [Senapati 2013](1). In our series the overall medium term recurrence rate post LVMR was 3%, a figure comparable to the 5% reported by D’Hoore in 42 patients with a median follow up of 61 months (2004)(2) and 3-4% reported in several other series [Smart 2013](7). The initial series reported by this unit reported a zero recurrence rate [3] highlighting the need for medium to long term follow-up. Importantly, our current series also reports a group with longer term follow up. Results are demonstrated to be sustainable with a recurrence rate of 3.3% in this group and no recurrences seen after 5 years.

 

LVMR has been demonstrated to be safe in the elderly population with rectal prolapse [Wijffels 2010](4). Our series reports a low rate of readmission and medical complications in a pre-dominantly elderly group. However the two mortalities reported highlight potential hazards and the need to consider early re-intervention.  

 

In addition, this series has demonstrated a significant improvement in quality of life for patients undergoing LVMR that is maintained at a median last follow up of 4 years. The PROSPER trial also noted sustained improvements in quality of life from baseline to the early post-operative period, and over the 3 years of follow up, for all methods of prolapse repair [Senapati 2013](1). However, they also found that having a recurrence was found to have an adverse impact on quality of life. This series has demonstrated that patients with a recurrence can achieve the same sustained improvements in QoL after redo surgery by LVMR as those undergoing primary repair.

 

A significant improvement in faecal incontinence was also seen at last follow up as judged by Cleveland Clinic incontinence scores. Several studies have documented improvements in the numbers of patients suffering incontinence [Lechoux 2005, D’Hoore 2004](2, 8) and others have used objective scores after the operation to demonstrate this [Formijne Jonkers 2013](9). Our series is important in quantifying a change in objective scores after the operation compared to before. Restricting dissection anterior to the rectum in LVMR also reduces post-operative constipation [Boons 2010](5) and is associated with good functional results [Lechoux 2005] (8). Relief of symptoms of sexual dysfunction, with a general improvement in respondent’s sex lives, was observed in this study in keeping with other studies [10].

 

Laparoscopic approaches have been associated with lower morbidity and earlier discharge than other methods of prolapse repair [Tou 2008, Purkayastha 2005](11,12) Daycase surgery is possible in selected patients [Powar 2013](13). A previous report from this institution has suggested that most complications, including recurrence, after LVMR are amenable to correctional surgery. Re-do LVMR or sometimes just re-attaching a detached mesh, is associated with improvement in overall function [Badrek Al-Amoudi 2013](6). This current series also provides evidence that LVMR is a useful technique after failed perineal repair, with results comparable to primary repair.

 

Concerns regarding mesh erosions highlight the need for long term follow up. A mesh erosion rate of 3.6% is reported here, mostly through the vagina. Some changes were made across this series, including the type of mesh used, to try to limit the potential for complications and in line with suggestions made at a national level [Mercer-Jones 2014](14). However, the optimal mesh for LVMR has not been established [Smart 2013](7). National reporting of outcomes and complication rates will help decision-making about techniques for mesh rectopexy, and aid informed consent for patients.

 

The results described in this paper reflect those of an experienced surgical team in a tertiary referral centre. Whilst this paper benefits from large numbers and follow up, only a third of patients returned sufficient data to analyse quality of life changes over a sustained period of time. Other large studies have also suffered with limits in response rate [Senapati 2013, Formijne Jonkers 2013](1, 9). It is important that surgeons encourage patient reporting of outcomes and prospective registries may again help collate this information.

 

In conclusion this series demonstrates that LVMR can be safely used to manage full thickness rectal prolapse and that this technique produces long term functional improvements. Outcome data for redo surgery in those with previous failed perineal procedures was similarly good.

 

 

Table 1 Demographics and pre-operative findings

 

Patient Characteristic

N (%)

Median Age (years)

Gender

     Male

     Female

ASA grade

     ASA I

     ASA II

     ASA III

     ASA IV

 

BMI

 

Previous surgery for rectal prolapse

     Delorme’s

     Repeated Delorme’s

     Altemeier procedure

     Rectopexy

 

 

Pre-operative Wexner Score

Pre-operative ODS score

 

69 (18-93)

 

24 (12.6)

166 (87.4)

 

58 (30.5)

79 (41.6)

49 (25.8)

4 (2.1)

 

25(16-38)

 

 

33

5

1

3 LVMR

3 posterior rectopexy- 1 with resection

 

9 (0-20)

16 (6-26)

 

 

Table 2 Details of operative procedure and outcome

 

Procedure Characteristic

N (%)

Additional procedure performed

    Orr-Loygue

    LVMR and anterior colporraphy

    LVMR and posterior STARR

    LVMR and PPH

 

Median length of stay (range)

    Day case

    24 hour stay

 

Complications

    60 day mortality

    Re-operation- enterotomy

    Re-operation- diverticular perforation

    Re-operation- small bowel obstruction

    Mesh complications

        Vaginal erosion

        Rectal erosion

        Rectovaginal fistula

    Re-admission

        Port site hernia

        Constipation

        Pneumonia

        Arrhythmia

        Diarrhoea

        Peptic ulcer

        Pain

 

3

7

10

2

 

2.2 days (0-45)

8 (4)

97 (51)

 

 

2 (1.1)

1 (0.5)

1 (0.5)

1 (0.5)

7 (3.7)

4 (2.1)

2 (1.1)

1 (0.5)

 

1 (0.5)

3 (1.6)

2 (1.1)

2 (1.1)

1 (0.5)

2 (1.1)

1 (0.5)

 

 

Table 3 Further procedures required

 

Repeat Procedures Required

N (%)

Redo LVMR

Local mesh excision

Laparoscopic mesh removal

Port site hernia

STARR

Neuromodulation

PPH

Biofeedback

Proctectomy

Rectovaginal fistula repair

 

8 (4.2)

3 (1.6)

3 (1.6)

1 (0.5)

7 (3.7)

3 (1.6)

3 (1.6)

14 (7.4)

1 (0.5)

1 (0.5)

 

 

 

 

 

 

 

 

 

 

References

 

1.            Senapati A, Gray RG, Middleton LJ, Harding J, Hills RK, Armitage NC, et al. PROSPER: a randomised comparison of surgical treatments for rectal prolapse. Colorectal Dis. 2013 Jul;15(7):858-68.

2.            D'Hoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg. 2004 Nov;91(11):1500-5.

3.            Slawik S, Soulsby R, Carter H, Payne H, Dixon AR. Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction. Colorectal Dis. 2008 Feb;10(2):138-43.

4.            Wijffels N, Cunningham C, Dixon A, Greenslade G, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse is safe and effective in the elderly. Does this make perineal procedures obsolete? Colorectal Dis. 2011 May;13(5):561-6.

5.            Boons P, Collinson R, Cunningham C, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation. Colorectal Dis. 2010 Jun;12(6):526-32.

6.            Badrek-Al Amoudi AH, Greenslade GL, Dixon AR. How to deal with complications after laparoscopic ventral mesh rectopexy: lessons learnt from a tertiary referral centre. Colorectal Dis. 2013 Jun;15(6):707-12.

7.            Smart NJ, Pathak S, Boorman P, Daniels IR. Synthetic or biological mesh use in laparoscopic ventral mesh rectopexy--a systematic review. Colorectal Dis. 2013 Jun;15(6):650-4.

8.            Lechaux D, Trebuchet G, Siproudhis L, Campion J. Laparoscopic rectopexy for full-thickness rectal prolapse: a single institution retrospective study evaluating surgical outcome. Surg Endosc. 2005 Apr; 19 (4): 514-8

9.            Formijne Jonkers HA, Poierrie N, Draaisma WA, Broeders IA, Consten EC. Laparoscopic ventral rectopexy for rectal prolapse and symptomatic rectocele: an analysis of 245 consecutive patients. Colorectal Dis. 2013 Jun;15(6):695-9.

10.             Wong M, Abet E, Rigaud J, Frampas E, Lehur P, Meurette G. Minimally invasive ventral mesh rectopexy for complex rectocele: impact on anorectal and sexual function. Colorectal Dis. 2011 June; 13: e320-e326

11.            Purkayastha S, Tekkis P, Athanasiou T, Aziz O, Paraskevas P, Ziprin P, et al. A comparison of open vs. laparoscopic abdominal rectopexy for full-thickness rectal prolapse: a meta-analysis. Dis Colon Rectum. 2005 Oct;48(10):1930-40.

12.            Tou S, Brown SR, Malik AI, Nelson RL. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev. 2008(4):CD001758.

13.            Powar MP, Ogilvie JW, Jr., Stevenson AR. Day-case laparoscopic ventral rectopexy: an achievable reality. Colorectal Dis. 2013 Jun;15(6):700-6.

14.            Mercer-Jones MA, D'Hoore A, Dixon AR, Lehur P, Lindsey I, Mellgren A, et al. Consensus on ventral rectopexy: report of a panel of experts. Colorectal Dis. 2014 Feb;16(2):82-8.

 

 

 

 

 

 


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