laparoscopic ventral rectopexy
DESCRIPTION
Journal presentation for colorectal society Dec 2014TRANSCRIPT
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Laparoscopic Ventral Rectopexy for Fecal Incontinence Associated with High-grade Internal Rectal ProlapseOxford Pelvic Floor CentreDepartment of Colorectal SurgeryOxford, UK
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Fecal incontinence Debilitating25% of institutionalized populationFactorsSphincterNeurologicalCNSStool consistencyDrossman et al. US householder survey of functional gastrointestinal disorders: prevalence, sociodemography and health impact. Dig Dis Sci. 1993;38:1569-1580
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Rectal prolapse & IncontinenceComplex interactionAnal resting pressureStretching of internal sphincterRectoanal inhibitory reflex (RAIR) disturbance Incomplete emptyingFarouk, Duthie. Rectal prolapse and rectal invagination. Eur J Surg. 1998;164:323-332
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Corrective proceduresMultiple over 50 yearsHigh morbidityVariable resultsLaparoscopic ventral rectopexy? (LVR)Asman HB. Internal procidentia of the rectum South Med J 1957;50:641-645
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MethodsAug 2009 July 2011180 subjects with fecal incontinencefailed maximal medical treatment74 LVRWorkupDefecating proctogramAnorectal physiologyEndoanal USEUAOxford Prolapse Grade
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Oxford Prolapse Grade
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QuestionnairesBefore & 1 year after surgeryRockwood Fecal Incontinence Severity IndexIncontinence
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Agachan-Wexner Constipation Score (1-5)obstruction
FISI score decrease
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StatisticsMean, median with SDWilcoxon signed rank testComparing improvement>50% FISI = successPatient group comparisonChi-square, Fisher exact testContinuous variables Mann Whitney testPearson correlation- FISI:pre-op squeeze increment
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Results74 LVR72 completed duration of study52 (72%) proctogramRemainder EUAComplications in 9 patients (13%)Urinary retention 7Port site infection 1Mesh erosion @5 mths - 1
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Results @1 yearMedian FISI score 31 15EUA grp: 38 16Proctogram grp: 30 12Similar improvementsOxford III and IVSimilar FISI scores
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Results21 patients completedly continent (29%)53 patients FISI improved >25%40 patients improved >50% (56%)4 patients no change (6%)8 patients worse off (11%)
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Additional intervention14 patients additional surgical procedure12 patients sacral neuromodulation2 patients repeat LVR for residual posterior prolapse
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Results Wexner scoreSignificantly reduced (median score)13 vs 8 (p< 0.001)6 patients (8%) minor deterioration Mean increase 1.3
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Results: Prediction of outcome***Preop squeeze increment is an independent predictive factor of LVR success
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DiscussionComparing Functional OutcomeFISIWexnerMore than half showed procedural success1/3 cured
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DiscussionFecal incontinent 27% has prolapseAsymptomatic prolapse at menopause 23%
Why correction of prolapse in the symptomatic population actually improves symptoms?Lazorthes et al. Is rectal intussusception a cause of idiopathic incontinence? Dis Colon Rectum. 1998;41:602-605Goei & Baeten. Rectal intussusception and rectal prolapse: Detection and postoperative evaluation with defecography. Radiology. 1990;174:124-126
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Available dataBristol group91%Int & externalIhre & Seligson77%internalDelemarre62% internalPortier39/4098%Orr-Loygue rectopexy
Samaranayake 45%int & external(systematic review of 12 case series, 728 patients)
- DiscussionImprovement greater in patients with low squeeze increment (
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Why LVR works?Delemarre et al:Anorectal physiology in 9 patientsBefore & after rectopexy
Significant increase in maximal squeeze increment in patients regained continencePartial restoration of pelvic floorMore effective active and reflexive anal sphincter action
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Why LVR worksAbolition of high rectal pressure wavesRecovery of internal anal sphincter electromyographic activityImprovement in anorectal sensationIncrease in anal resting pressure
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LimitationLack of anorectal manometry dataPost-rectopexy pelvic floor imaging
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CommentsLVR has a roleWhere does LVR stand in the treatment algorithm?Compared to sacral neurostimulationEqual?Better?
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New questions to be answeredPatients with fecal incontinence associated with high grade internal rectal prolapseLVR+/- Neurostimulation
***considering complications eg. mesh erosion***general anaesthesia vs DC (neurostim.)
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Thank you