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Surgery for obstructed defecation (OD) caused by internal rectal prolapse has suffered a bad reputation. A classical posterior rectopexy, shown to denervate the autonomic supply of the rectum [1, 2], worsens constipation for 50% of patients and has been abandoned [3]. The novel nerve-sparing laparoscopic anterior or ventral rectopexy, which improves constipation in cased of external prolapse [4], may alter the way internal rectal prolapse is managed.
Your recent publication describing 17 patients who underwent a laparoscopic ventral rectopexy for OD syndrome causes us concerns [5]. The indication for surgery is not made clear. A variety of findings were shown by defecating proctography, including rectocoele and enterocoele, but only four patients had rectal intussusception. For most of the patients, the Longo OD syndrome score actually deteriorated and, inconceivably, the patients were happy with worse constipation postoperatively. The morbidity rate of almost 50%, including a rectal perforation, a small bowel perforation, a mesh infection and explantation, and a peripheral nerve injury, is unacceptable.
In our experience, rectoanal intussusception or a high-grade internal rectal prolapse plays the central role in OD. When OD is managed by dedicated functional colorectal surgeons through a specialist pelvic floor clinic, with multidisciplinary review of clinical, radiologic, and physiologic consideration, and careful case selection, the outcomes of anterior rectopexy need not be so poor.
In a similar 3-year period, we treated 75 patients with OD and high-grade (intra-anal) internal prolapse by laparoscopic anterior rectopexy, with 4% morbidity and 75% to 80% improvement in OD symptoms as well as significant reduction in median Wexner OD scores (13 to 4; p < 0.0001) [6]. Very similar results have recently been published by Slawik [7]. If internal prolapse surgery is to reestablish its reputation, we must do better.
References
Speakman CT, Madden MV, Nicholls RJ, Kamm MA (1991) Lateral ligaments division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study. Br J Surg 78:1431–1433
Mollen RM, Kuijpers JH, van Hoek F (2000) Effects of rectal mobilization and lateral ligaments division on colonic and anorectal function. Dis Colon Rectum 43:1283–1287
Orrom WJ, Bartolo DC, Miller R, Mortensen NJ, Roe AM (1991) Rectopexy is an ineffective treatment for obstructed defaecation. Dis Colon Rectum 34:41–46
D’Hoore A, Cadoni R, Penninckx F (2004) Laparoscopic ventral rectopexy for total rectal prolapse: long-term outcome. Br J Surg 91:1500–1505
van den Esschert JW, van Geloven AA, Vermulst N, Groenedijk A, de Wit LT, Gerhards MF (2008) Laparoscopic ventral rectopexy for obstructed defecation syndrome. Surg Endoscopy March 5 [Epub ahead of print]
Collinson R, Cunningham C, Lindsey I (2008) Laparoscopic anterior rectopexy for external and internal rectal prolapse (abstract). Dis Colon Rectum 51:661–662
Slawik S, Soulsby R, Carter H, Payne H, Dixon AR (2007) Laparoscopic ventral rectopexy, posterior colporrhaphy, and vaginal sacrocolpopexy for the treatment of rectogenital prolapse and mechanical outlet obstruction. Colorectal Dis 10:138–143
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Wijffels, N., Cunningham, C. & Lindsey, I. Laparoscopic ventral rectopexy for obstructed defecation syndrome. Surg Endosc 23, 452 (2009). https://doi.org/10.1007/s00464-008-0192-6
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DOI: https://doi.org/10.1007/s00464-008-0192-6