Factors Influencing Morbidity after Rectopexy for Posterior Pelvic Floor Disorders

Transcription

1 Factors Influencing Morbidity after Rectopexy for Posterior Pelvic Floor Disorders Ayca Fatma Gultekin 1, Jean-Benoit Hardouin 2, Guilé Romain 3, Myriam Boutami 1, Paul-Antoine Lehur 1, Guillaume Meurette 1 1 Clinique de Chirurgie Digestive ét Endocrinienne, 2 Département de Statistique, 3 Département d information Médicale University Hospital of Nantes, Nantes, FRANCE

2 No conflict of interest to disclose

3 Background Abdominal Rectopexy : A lower rate of long-term recurrence than perineal procedures, The gold standard treatment for rectal prolapse Perineal Abdominal

4 Background In France, ventral rectopexy (VR) is the most common procedure for the treatment of posterior pelvic floor disorders Laparoscopic VR has gained wide adaptation among French surgeons MINIMAL INVAZIVE Elderly Short Stay Low Morbidity VENTRAL Constipation Uro-gyno advantages ABDOMINAL Improved incontinence Low recurrence Ventral Rectopexy

5 Background The incidence of pelvic organ prolapse (POP) usually increases with advancing age POP patients usually have mild-severe comorbidities Detailed evaluation and defining possible risk factors preoperatively are mandatory for successful surgical outcomes after VR

6 Objective The aim of this study was to identify predictive factors for postoperative morbidity after VR in France using the national database.

7 Methods I Data Source PMSI; the national medical information program is a prospectively constructed database covering all public and private hospitals in France. CCAM; a national standardized medical procedures classification

8 Methods II - Patient Selection The clinical data of patients who underwent VR in year 2010 was analyzed All discharges with open or laparoscopic rectopexy CCAM code HJDA 001 : Open rectopexy HJDC 001: Laparoscopic rectopexy

9 Methods III Predictive Factors Evaluated Hospital volume Preoperative Factors Age Gender Diagnosis Comorbidities Perioperative factors Procedure type Adhesions

10 Methods IV Outcomes Measured Postoperative complications Clavien-Dindo Grading System of Complications Minor Complications Grade I and II Major Complications Grade III, IV and V

11 Methods V Statistical Analysis Data were described using mean (± SD) and median (min-max) values for continuous variables, and (%) for qualitative variables Univariate and multivariate analysis were assessed using logistic regression For multivariate analysis, stepwise selections of variables were performed The type I error was defined at 5% for all the analyses

12 Results A total of 12,600 patients operated on for POP during the study period 4877 patients underwent ventral rectopexy Laparoscopic 574 Open

13 Results I-Hospital volume and patient characteristics No. of patients (n=4877) Hospital volume Mean No. of case/year (±SD) 48.9 (±45.5) Median No. of case/year (min-max) 36 (1-183) Age Mean, years (±SD) 62.9 (±12.4) Median, years (min-max) 63 (16-97) 70 years, n (%) 1505 (30.8) 80 years, n (%) 400 (8.2) Gender Male, n (%) Female, n (%) 117 (2.4) 4760 (97.6) Diagnosis, (%) Vault prolapse 48.5 Rectal prolapse 24.1 Cystocele 14.6 Rectocele 10.1 Fecal incontinence 1.3 Enterocele 0.9

14 Results II-Comorbidities and perioperative factors No. of patients (n=4877) Comorbidity, (%) Hypertension Cardiac disease Chronic lung disease Diabetes Neurologic disease Depression Peripheral vascular disease Anticoagulation Hyperlipidemia Obesity Smoking Procedure type, n (%) Open VR 574 (11.8) Laparoscopic VR 4303 (88.2) Adhesions, (%) 1.0

15 Results III-Postoperative minor complications No. of patients (n=4877) Postoperative minor complications, (%) 6.9 Urinary tract infection 3.4 Urinary retention 1.0 Hematoma or hemorrhage 0.8 Ileus 0.6 Wound infection 0.5 Burst stiches or sutures 0.5 Septic phlebitis 0.02

16 Results IV-Postoperative major complications No. of patients (n=4877) Major postoperative complications, n (%) 47 (1.0) Accidental puncture or laceration 0.6 Intra-abdominal abscess 0.1 Sepsis 0.1 Acute respiratory failure 0.1 Injury to blood vessel 0.02 Injury to rectum 0.02 Cardiac arrest 0.02 Pulmonary Thromboembolism 0.04

17 day Results V-Factors Associated with postoperative-30 morbidity: Univariate Analaysis

18 Results VI-Predictors of postoperative minor complications: Multivariate Analysis OR p-value Age Diagnosis Vault prolapse Rectocele Procedure Type Open VR 2.16 <0.001 Adhesions Pseudo R² 4%

19 Results VII-Predictors of postoperative major complications: Multivariate Analysis OR p-value Comorbidity Obesity Procedure Type Open VR 3.21 <0.001 Adhesions Pseudo R² 5%

20 Conclusion Our study has identified specific characteristics, including age 80 y, rectal prolapse, open VR and adhesions, as major risk factors for morbidity Open procedure and adhesions as the strongest predictors of postoperative morbidity after VR in patients with POP It suggested that a laparoscopic approach is associated with a decreased postoperative morbidity The benefit of laparoscopy observed in the present study might have important implications and prevent postoperative morbidity following VR if implemented more widely

21 THANK YOU