The Impact of Laparoscopic Resection Rectopexy in Patients with Total Rectal Prolapse

Transcription

1 MILITARY MEDICINE, 170, 9:743, 2005 The Impact of Laparoscopic Resection Rectopexy in Patients with Total Rectal Prolapse Guarantor: Lt Col Sezai Demirbas Contributors: Lt Col Sezai Demirbas*; Col M. Levhi Akin*; Capt Yavuz Kurt*; Ibrahim Ogün ; Navy Capt Tuncay Çelenk* Total rectal prolapse is a disabling disease. The aim of this study was to evaluate pain management, hospital stays, constipation, and continence status among military personnel who underwent laparoscopic surgery. Forty patients (mostly men) underwent laparoscopic rectopexy (LR) or laparoscopic resection rectopexy (LRR). Colonic transit time, postoperative pain scores, preoperative and postoperative anal function, and changes in constipation were assessed. The median operation times for LR and LRR were 126 and 223 minutes, respectively. The median postoperative hospital stays were 3 and 6 days for LR and LRR, respectively. Patients needed fewer analgesics in a short postoperative period. However, there was no difference between the two groups in analgesic requirements. Continence improved for 71% of patients, but constipation was treated for 50% of affected patients. No recurrences were noted in the follow-up periods, which were 13 and 22 months for the LRR and LR groups, respectively. The quality of life for the patients who underwent LR was not as good as that for the patients who underwent LRR, at the end of 1 year. We eliminated total rectal prolapse and almost cured incontinence by using laparoscopy, although the disadvantageous aspects were long operation times and suboptimal healing with respect to constipation and related symptoms. LRR is the more feasible procedure, with the emphasis on elimination of incontinence and constipation, producing a better quality of life for patients, in addition to short hospitalizations, necessity for analgesia for a short time, and return to hard training field activities in a short time among military personnel. Introduction otal rectal prolapse with chronic constipation and anal incontinence is a devastating disorder. Rectopexy with or T without bowel resection is the most frequent surgical procedure, with 0 to 9% recurrence rates in many years. 1,2 Although constipation and incontinence are devastating difficulties for patients (range, 45 75%), complete correction of constipation is poor, 3 7 whereas incontinence can be treated to nearly normal status. Perineal procedures are usually used for elderly and high-risk patients, with high recurrence rates (9-35%) and insignificant improvement in functional status. 2,3 In the past 5 years, with the use of laparoscopy, posterior mesh laparoscopic rectopexy (LR) and hand-assisted laparoscopic resection rectopexy (LRR) have become more common, with the benefits of low recurrence rates, improved anal functions, and shorter hospitalization. 1,6,8 13 The purpose of this study was to assess the effects of laparoscopic procedures with sigmoid resection on *Department of General Surgery, Haydarpasa Teaching Hospital, Gulhane Military Medical Academy, Istanbul, Turkey. Department of General Surgery, Mevki Military Hospital, Ankara, Turkey. This manuscript was received for review in December The revised manuscript was accepted for publication in August Reprint & Copyright by Association of Military Surgeons of U.S., postoperative bowel characteristics and anal canal function among active duty military personnel with total rectal prolapse. Methods Between January 1999 and June 2003, 40 patients (two women) underwent laparoscopic repair of total rectal prolapse (Table I). The median age was 24.7 years for patients with LR and 26 years for patients with hand-assisted LRR. Twenty-two patients underwent LR and 18 underwent LRR. No case was converted to an open procedure. The follow-up period was 21.6 months for patients with LR and 13.3 months for patients with LRR (Table I). Each patient underwent a detailed history of bowel function, physical examination, rectal digital examination, rectosigmoidoscopy, and barium-contrast enema study. Anal canal function was evaluated with the fecal incontinence severity index (FISI) scoring system, reflecting both the severity and frequency of complaints. 5,14 Preoperative and postoperative anal manometry (Albynmedcal, Mui Scientific, Mississagua, Canada) was performed in cases with FISI scores of 4. Anal manometry and FISI scoring were performed by a senior registered nurse associated with this study but not involved in the surgical process. With such defecation characteristics as presence of hard stool, use of laxatives, incomplete evacuation, and use of digitations, fewer than two bowel movements per week and straining 30% of defecation times were accepted as constipation. Selected patients underwent defecography to evaluate the paradoxical puborectalis function. Constipated patients also were evaluated with colonic transit time (CTT) assays using radiolucent markers (Time Marker, Sapimed, Alessandria, Italy). The upper limit for CTT was 90 hours. 15 For surgery, after mechanical bowel cleansing, patients were taken to a modified lithotomy position. Prophylactic antibiotic and low-molecular weight heparin for older patients were administered. After pneumoperitoneum, a 10-mm trocar for a camera was placed into the abdomen at the umbilicus; one of the two 5-mm trocars was placed on the point crossing the lateral edge of the rectus muscle and the line between the umbilicus and cristailiaca (iliac crest) superior anterior in both lower abdominal quadrants. An extra trocar for retraction was used throughout the symphis pubis or left lumbar quadrant. After the visceral peritoneum over the rectum was opened, retrorectal mobilization was performed to the levator ani muscle. Special attention was given to identifying both ureters and the nerve plexus. Lateral ligaments were not divided. Anterior dissection was carried out to 4 to 5 cm deep from peritoneal reflection. Propylene mesh ( cm in size) was sutured on the posterior distal wall of the rectum with 2-0 polypropylene sutures (Ethibond 2-0, J& J Ethicon, Edinburgh, United King- 743

2 744 LRR for Total Rectal Prolapse TABLE I DEMOGRAPHIC AND HISTORICAL DATA FOR PATIENTS WHO UNDERWENT LAPAROSCOPY LR (N 22) LRR (N 18) p Age (years) 24.7 (19 57) 26 (21 37) Gender (M/F) 21/1 17/1 Years before surgery, mean SD (range) (1 8) (3 12) Length of prolapsed bowel segment in physical (75 12) (5 15) examination (cm), mean SD (range) Solitary rectal ulcer, (no.) 3 1 Previous perineal operation (no.) 4 1 Additional procedures performed (no.) 1 Family history (no.) 2 5 Rectocele (no.) 1 Follow-up period (months), mean SD (range) (4 34) (3 23) dom) intracorporeally. Then the proximal part of the mesh was anchored on the promontory by using titanium tacking (Protack, Autosuture, Norwalk, Connecticut). The open peritoneum was closed in each case. Sigmoid resection was performed by using a hand-assisted apparatus (Intromid, Medtech Ltd., Dublin, Ireland) through a 7-cm, infraumbilical, vertical incision. After the rectum was mobilized, the surgeon introduced his left hand into the abdomen and lifted the redundant sigmoid colon up. After the sigmoid mesentery was freed, the sigmoid colon was cut at the rectosigmoid junction with an endoscopic stapler (Proximate ILS curved intraluminal stapler, Ethicon Endo-Surgery, Cincinnati, Ohio). The sigmoid colon was exteriorized and resected. A stapled anastomosis was fashioned intracorporeally. At the end of this process, mesh was placed in the same location as mentioned above. No nasogastric tube was left. Liquid intake was given on postoperative days (PODs) 1 to 3 (Table II). For pain management, during the operation bupivacaine HCl (2 ml, 0.5% Marcaine, Astra-Zeneca, Istanbul, Turkey) was injected around the edges of the incision. Pethidine HCl (100 mg/2 ml, 1 mg/kg per dose, Aldolan, Liba, Turkey) was injected intramuscularly in the first 2 hours postoperatively. An oral analgesic (ibuprofen, 600 mg two times per day, Yeni Ilac, Istanbul, Turkey) was prescribed from POD 2 to POD 5. A visual analog scale (VAS) for postoperative pain severity was used. The severity of postoperative pain was assessed at 4, 8, 16, 36, and 72 hours and at the end of 1 week. Patients quality of life was evaluated by using the quality of life for fecal incontinence (QoL-FI) questionnaire. 5,16 Each patient was monitored at the 6th week. One year later, the surgery and anastomosis were observed in the first follow-up examination. Statistical analysis was performed comparing the means for the two groups. A nonparametric test (Wilcoxon test) was used to compare the means of the different groups; p 0.05 was considered statistically significant. Results LR and LRR were completed in all cases. The mean operation time was statistically longer for LRR than for LR (p 0.001). The hospital stay was significantly shorter for the LR group than for the LRR group (p 0.001) (Table II). TABLE II POSTOPERATIVE PATIENTS CHARACTERISTICS LR (N 22) LRR (N 18) p Mean operation time (minutes), mean SD (range) (92 175) ( ) Resected bowel segment (cm) 29 (21 39) First oral intake POD 1 POD 2 3 Hospitalization (days) 3 (1 5) 6.1 (3 13) Postoperative VAS score in first 24 hours 4 3 POD (1 7) 1.6 (0 7) Complications (no.) Major (%) (total, 12.5%) Bleeding a 1 (upper GI) 1 (PSV) Pulmonary infection 0 1 Port site hernia 0 1 Retrograde ejaculation 1 0 Minor (%) (total, 17.5%) Urinary retention 2 2 Urinary tract infection 1 1 Port site infection 1 0 a Presacral venous (PVS) bleeding was observed during surgery. It was controlled with tamponade; GI, gastrointestinal tract.

3 LRR for Total Rectal Prolapse 745 Pain Management To resolve postoperative pain, one dose of pethidine HCl (1 mg/kg per dose) was injected at the end of surgery and, if necessary, given at 8- to 12-hour intervals in the first 24 hours. Each patient took ibuprofen two times per day, orally. The mean VAS scores for LR and LRR decreased to 1.3 and 1.6, respectively, from POD 2 to POD 5 (not statistically significant) (Table II). Postoperative Complications Bleeding and retrograde ejaculation occurred as major complications. Approximately 17% of patients had major complications in the LRR group, which was higher than that observed in the LR group. Urinary retention in both groups was frequently seen as a minor complication. Total major and minor complication rates were 12.5% and 17.5%, respectively (Table II). Evaluation of Anal Function Eighteen (45%) patients had anal incontinence, with a mean FISI score of Eight of the 18 patients were in the LRR group. Considering the preoperative and postoperative findings, the maximal resting pressure and minimal squeezing pressure increased to 2 times the preoperative levels. The minimal sensible volume decreased to 40 to 45 ml of air. When comparing the outcomes revealed in the 6th week and at the end of 1 year, there was no significant difference except that the failure rate for continence status increased to 17% (Table III). Assessment of Constipation Characteristics Before the laparoscopic procedures, 21 (52.5%) patients suffered from constipation and related symptoms (Table IV). The mean CTT was hours preoperatively. The CTT for the patients who underwent LR and LRR decreased to 92.8 and 41 hours, respectively (p and p 0.001, respectively). Six weeks after surgery, constipation and related symptoms were resolved for 15 (71.4%) of 21 patients. At the end of 1 year, 7 (33.3%) of 21 patients remained constipated despite the surgery. All 14 patients with failure (constipation after surgery) were from the LR group. Considering the two surgery groups, 7 (50%) of 14 patients remained constipated after the surgical procedure. Quality of Life Thirty-five patients (18 in the LR group and 17 in the LRR group) were evaluated with the QoL-FI questionnaire. In the LR group, whereas 35% of patients defined their condition as bad, at the end of 1 year the value was 53%. In contrast, 80% of patients who underwent LRR declared that their health and continence were better. Discussion Transabdominal laparoscopic procedures with very low morbidity and mortality rates could be performed even for elderly patients in recent years. 1,3,6,7,9,10,13,17 Surgeons have favored LR procedures because of less pain, short hospital stays, and lower recurrence rates with better cosmesis. 5,6,9,17 In this study, analgesia was also achieved in a short time period, as stated in some TABLE III OUTCOMES OF ANAL MANOMETRY WITH PREOPERATIVE AND POSTOPERATIVE MEASUREMENTS Mean SD (Range) p (6 Weeks, 1 year) PO, 6 Weeks PO, 1 Year LR (N 10) LRR (N 8) LR (N 10) LRR (N 8) Preoperative (N 18) (45%) Maximal resting pressure (mm Hg) (9 33) (21 65) (22 60) 0.001, Minimal squeezing pressure (mm Hg) (37 76) (42 129) (75 121) 0.001, Minimal sensible volume (ml air) (40 110) (30 60) (30 65) 0.001, Postoperative continence status Patients with incontinence (no.) FISI score (7 19) Failure (%) (Mean, 11.1) (Mean, 16.7) PO, postoperative.

4 746 LRR for Total Rectal Prolapse TABLE IV COMPARISON OF PREOPERATIVE AND POSTOPERATIVE BOWEL MOVEMENT FREQUENCIES Postoperative, 6 weeks Postoperative, 12 Months Preoperative LR (N 14) LRR (N 7) LR (N 14) LRR (N 7) Total (%) Constipation (no.) 21 (52.5) 5 (35.7) 1 (14.3) 7 (50) 0 Hard stool (no.) Need for laxatives (no.) Use of digitation (no.) Bleeding (no.) Abdominal pain (no.) CTT (hours), mean SD (70 360) (48 220) (19 56) a (range) QoL-FI questionnaire (n 35) (no.) Perfect Good Fair Bad (%) 6 (35.3) 2 (13.3) 9 (53) 2 (13) 28.6 a Probability values were compared between the preoperative CTT and postoperative CTT of patients with resection rectopexy and the ones without rectopexy (laproscopic rectopexy alone). p 0.013; p articles. 2,6,7,10 The operation time for LRR was quite long, which was a disadvantage of the procedure. However, with more experience, the time decreased by 24.2 minutes, particularly in the last seven procedures. Otherwise, the operation time was not unlike that stated in the literature. 2,3,6,7,9,17 Short hospital stays are a major point in choosing laparoscopic surgery for military personnel on crucial duty. Whereas in the literature the average hospital stay for a patient who underwent LR was 5 days, 2,6,7,10 in this study it was 3 days for the LR group and 6 days for the LRR group. Despite a longer hospitalization time than that stated in the literature for patients who underwent LRR, the time was reduced with more experience and increased numbers of patients. The military personnel mostly could be back to their critical tasks in 2 to 3 weeks. Although recurrence rates were reported as 0 to 9%, 2,18 in our study no recurrence was observed during the follow-up period, which was approximately 13 to 22 months. Major (12.5%) and minor (17.5%) complications were observed. The reason for elevated complication rates might be related to modest initial experience, inattentive surgical technique, and limited numbers of patients. There is still controversy regarding the mechanism of chronic constipation. There are some abnormalities of excess length of the colon and function of the pelvic floor musculature among patients with total rectal prolapse. 3,4,17,19 24 The length of the colon was managed only with surgery, as stated by Frykman and Goldberg. 25 Approximately 75% of patients with prolapse had some problems with evacuation because of the obstructing segment. 19 Denervation by full rectal mobilization causing dysmotility of the rectum, rectal wall thickness resulting from rectal mobilization, redundant sigmoid colon filling the space of Douglas, and prosthetic material fixing the rectum on the presacral fascia are several reasons why patients experience constipation. Duthie and Bartolo 21,25 also stated that the etiology of postoperative constipation was not clear. As did the other authors, they favored resection rectopexy. 3,19 23 After surgery, because of the impaired motility of the rectum resulting from fixation of its posterior wall on the sacrum and division of the lateral ligaments, the rectum acts as a functional obstructing segment, contributing to constipation. 3,19,24,25 Various authors stated the same theory. 2,3,7,19,20,23 In this study, 53% of patients had constipation before surgery and seven (34%) of those patients remained constipated 1 year later. Of the patients in the LR group, five were constipated at the 6th week and the number of patients increased to seven 1 year after surgery. No patient was left constipated in the LRR group when a bowel segment of 29 cm was removed. The mean CTT before surgery was also significantly decreased for all patients who underwent surgery, but it was almost normalized for the patients with LRR. Regarding the assessments, LRR should be the ideal procedure for patients with redundant sigmoid colon and chronic constipation with extended CTT. Rectoanal inhibition and abnormal anorectal sensation are reasons why patients with total rectal prolapse have anal incontinence. 3,17,20,21,26 In addition to an impaired internal anal sphincter, weakened pelvic floor muscles and ligaments and impaired somatic nerve stimulation were observed for these patients. 21,27 Improved function of the internal anal sphincter is agreed upon as a main factor for recovery of anal function. Rectopexy improves internal anal sphincter function and anorectal sensation. 2,3,7,19 21 However, Keighley et al. 28 showed no improvement in sphincter recovery in their series. 24 Duthie and Bartolo 21 declared that there was no improvement in resting sphincter pressures among patients undergoing surgical procedures with Ivalon and Marlex mesh. It was also stated that use of prosthetic mesh could be the reason why patients had no sphincter recovery after surgery, because of a possible dense tissue reaction blocking improvement of internal anal sphincter function, caused by mesh. 21 Both 6 weeks and 1 year after surgery, we determined that the maximal resting pressure and minimal squeezing pressure were increased into an acceptable range and the minimal sensible volume was reduced to a satisfying volume, which were statistically significant. Despite the increased pressures, two and three patients at the end of 6 weeks and 1 year, respectively, remained incontinent. This might be related to sigmoid resection resulting in quick CTT among patients with inadequate continence status. Other pa-

5 LRR for Total Rectal Prolapse tients facing difficult field training confirmed that their continence condition was not challenging. According to the QoL-FI questionnaire, almost 70% of patients who underwent LRR were satisfied with their health status related to anal function after surgery, which is a very important issue for military personnel performing hard field training activities. In this study with limited numbers of patients, the procedures of LR and LRR helped us attain more experience in the evaluation of patients with total rectal prolapse. As a result, laparoscopic surgery with sigmoid resection is a satisfactory procedure for military personnel, with short hospital stays, less required and shorter analgesia, return to normal training and sport activities in a short time, and practical correction of anal canal function, although with longer operation times and inferior continence outcomes than desired. References 1. 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