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BMC Surgery Nov 2023Obstructed defecation syndrome represents 50-60% of patients with symptoms of constipation. We aimed to compare the two frequently performed surgical methods,...
Laparoscopic ventral mesh rectopexy vs. transperineal mesh repair for obstructed defecation syndrome associated with rectocele: comparison of selectively distributed patients.
PURPOSE
Obstructed defecation syndrome represents 50-60% of patients with symptoms of constipation. We aimed to compare the two frequently performed surgical methods, laparoscopic ventral mesh rectopexy and transperineal mesh repair, for this condition in terms of functional and surgical outcomes.
METHODS
This study is a retrospective review of 131 female patients who were diagnosed with obstructed defecation syndrome, attributed to rectocele with or without rectal intussusception, enterocele, hysterocele or cystocele, and who underwent either laparoscopic ventral mesh rectopexy or transperineal mesh repair. Patients were evaluated for surgical outcomes based on the operative time, the length of hospital stay, operative complications, using prospectively designed charts. Functional outcome was assessed by using the Initial Measurement of Patient-Reported Pelvic Floor Complaints Tool.
RESULTS
Fifty-one patients diagnosed with complex rectocele underwent laparoscopic ventral mesh rectopexy, and 80 patients diagnosed with simple rectocele underwent transperineal mesh repair. Mean age was found to be 50.35 ± 13.51 years, and mean parity 2.14 ± 1.47. Obstructed defecation symptoms significantly improved in both study groups, as measured by the Colorectal Anal Distress Inventory, Constipation Severity Instrument and Patient Assessment of Constipation-Symptoms scores. Minor postoperative complications including wound dehiscence (n = 3) and wound infection (n = 2) occurred in the transperineal mesh repair group.
CONCLUSION
Laparoscopic ventral mesh rectopexy and transperineal mesh repair are efficient and comparable techniques in terms of improvement in constipation symptoms related to obstructed defecation syndrome. A selective distribution of patients with or without multicompartmental prolapse to one of the treatment arms might be the preferred strategy.
Topics: Humans; Female; Adult; Middle Aged; Rectocele; Defecation; Rectal Prolapse; Surgical Mesh; Treatment Outcome; Follow-Up Studies; Laparoscopy; Constipation; Hernia; Rectum
PubMed: 38001430
DOI: 10.1186/s12893-023-02206-0 -
Annals of Surgery May 2024Assess the effectiveness of sacral neuromodulation (SNM) versus personalized conservative treatment (PCT) in patients with refractory idiopathic slow-transit... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
Assess the effectiveness of sacral neuromodulation (SNM) versus personalized conservative treatment (PCT) in patients with refractory idiopathic slow-transit constipation (STC).
BACKGROUND
Evidence on SNM for idiopathic STC is conflicting and of suboptimal methodological quality.
METHODS
The No.2-Trial was a multicenter, open-label, pragmatic, randomized trial performed in 2 Dutch hospitals. Sixty-seven patients with idiopathic STC, a defecation frequency <3 per week and refractory (ie, unresponsive) to maximal conservative (nonoperative) treatment were included. Exclusion criteria included outlet obstruction, rectal prolapse, and previous colon surgery. Patients were randomized (3:2) to SNM (n=41) or PCT (n=26) with randomization minimization between February 21, 2017 and March 12, 2020. In SNM patients, an implantable pulse generator was implanted after a successful 4-week test stimulation. PCT patients received conservative treatment such as laxatives or retrograde colonic irrigation. The primary outcome was treatment success (defined as average defecation frequency ≥3 per week) after 6 months. Secondary outcomes included constipation severity, fatigue, quality of life, and adverse events. Analysis was according to intention-to-treat.
RESULTS
After 6 months, 22 (53.7%) patients were successfully treated with SNM versus 1 (3.8%) patient with PCT (odds ratio 36.4, 95% CI 3.4-387.5, P =0.003). At 6 months, SNM patients reported lower constipation severity and fatigue scores ( P <0.001) and improved quality of life compared with PCT ( P <0.001). Eight serious adverse events (6 SNM, 2 PCT) and 78 adverse events (68 SNM, 10 PCT) were reported.
CONCLUSIONS
SNM is a promising surgical treatment option in a homogeneous group of adults and adolescents with refractory idiopathic STC. No.2-Trial registered at ClinicalTrials.gov NCT02961582.
Topics: Adolescent; Adult; Humans; Conservative Treatment; Constipation; Electric Stimulation Therapy; Quality of Life; Treatment Outcome
PubMed: 37991178
DOI: 10.1097/SLA.0000000000006158 -
Medicine Nov 2023Due to the controversy on the feasibility of laparoscopic-assisted anorectoplasty (LAARP) for the treatment of the anorectal malformation (ARM) with rectobulbar fistula...
Due to the controversy on the feasibility of laparoscopic-assisted anorectoplasty (LAARP) for the treatment of the anorectal malformation (ARM) with rectobulbar fistula (RBF), this study aimed to compare the outcomes of LAARP and posterior sagittal anorectoplasty (PSARP) for ARM with RBF. Demographic data, postoperative complications, and bowel function of RBF patients who underwent LAARP and PSARP at 2 medical centers from 2016-2018 were retrospectively reviewed. Eighty-eight children with RBF were enrolled, including 43 in the LAARP group and 45 in the PSARP group. There were no significant differences in the sacral ratio (P = .222) or sacral agenesis (P = .374). Thirty-seven and 38 patients in the LAARP and PSARP groups were followed up for a median of 4.14 years. The postoperative complications were comparable between the groups (P = .624), with no cases of urethral diverticulum. The urination of all cases was normal and no evidence of cyst formation was found on MCU or MRI during the follow-up period. The incidence of rectal prolapse was similar between the 2 groups (9.3% vs 17.8%, P = .247). The groups had equivalent Bowel Function Score (15.29 ± 2.36 vs 15.58 ± 2.88, P = .645), but the LAARP group had better voluntary bowel movement (94.6% vs 84.2%, P = .148) by Krickenbeck classification. The intermediate-term outcomes of LAARP show that the urethral diverticulum was rare by the intraluminal incision of the fistular and the bowel function was comparable to that of PSARP in ARM with rectobulbar fistula. However, LAARP was associated with smaller perineal wounds.
Topics: Child; Humans; Infant; Anorectal Malformations; Retrospective Studies; Rectum; Laparoscopy; Rectal Fistula; Postoperative Complications; Urethral Diseases; Diverticulum; Anal Canal; Treatment Outcome
PubMed: 37986398
DOI: 10.1097/MD.0000000000035825 -
Internal Medicine (Tokyo, Japan) Jul 2024Rectal prolapse is typically treated surgically, and internal therapy has not been reported. We encountered a case of rectal prolapse that improved with an...
Rectal prolapse is typically treated surgically, and internal therapy has not been reported. We encountered a case of rectal prolapse that improved with an over-the-scope clip (OTSC) system. An 81-year-old woman complaining of anorectal pain underwent colonoscopy, and rectal prolapse was observed prior to colonoscopy. Unfortunately, rectal perforation occurred while attempting endoscopic reversal. The OTSC system was used to close the rectal perforation and subsequently improved her rectal prolapse, probably because the rectal wall was anchored to the retroperitoneum. This is the first report to show that rectal prolapse can be endoscopically improved and that an OTSC system might be a viable alternative method for managing inoperable rectal prolapse.
Topics: Humans; Rectal Prolapse; Female; Aged, 80 and over; Colonoscopy; Surgical Instruments; Treatment Outcome
PubMed: 37952946
DOI: 10.2169/internalmedicine.2815-23 -
Cirugia Espanola Feb 2024While haemorrhoidal dearterialization and mucopexy are accepted as a valid alternative to haemorrhoidectomy, differences exist regarding the fixed or variable location...
INTRODUCTION
While haemorrhoidal dearterialization and mucopexy are accepted as a valid alternative to haemorrhoidectomy, differences exist regarding the fixed or variable location of the arteries to be ligated. Our aim was to shed light on this issue of arterial distribution in candidates for surgery.
METHODS
The study included consecutive patients diagnosed with Goligher grade III and IV haemorrhoids, who had undergone Doppler-guided haemorrhoidal artery ligation (DG-HAL) and rectoanal repair (RAR) at 2 medical centres in Spain. The main objective was to evaluate the number and 12-h clock locations of arterial ligatures necessary to achieve Doppler silence.
RESULTS
In total, 146 patients were included: 111 (76%) men, and 35 (24%) women. Average age was 54 years (21-84). Grade III and grade IV haemorrhoids were diagnosed in 106 (72.6%) and 40 (27.4%) patients, respectively. The average number of ligatures per patient was 7 (range 2-12). Ligature percentages greater than 60% occurred at clock positions 7, 11, 10, 12, 9, and 1. The average number of mucopexies per patient was 3 (range 1-4). The most frequent mucopexy locations were the left posterior, right posterior, and right anterior octants.
CONCLUSIONS
While the greatest frequency of arterial ligatures occurred in odd-numbered clock positions, non-negligible percentages occurred in even-numbered clock positions, which, in our opinion, makes the use of Doppler necessary, given that arterial distribution is not the same in all patients. We also noted that more ligatures and mucopexies were needed on the right half of the rectal circumference than on the left side, suggesting greater right-side vascularization.
Topics: Male; Humans; Female; Middle Aged; Hemorrhoids; Ultrasonography, Interventional; Rectum; Hemorrhoidectomy; Arteries
PubMed: 37949364
DOI: 10.1016/j.cireng.2023.09.006 -
International Journal of Surgery Case... Nov 2023Sigmoid-rectal intussusception or invagination is an infrequently documented condition in the adult population, with only a handful of cases reported in the medical...
INTRODUCTION
Sigmoid-rectal intussusception or invagination is an infrequently documented condition in the adult population, with only a handful of cases reported in the medical literature. The underlying pathological mechanism involves impaired peristalsis, often attributed to a malignant tumor.
CASE PRESENTATION
A 78-year-old patient, with a history of abdominal pain and lower gastrointestinal bleeding, sought care at our emergency department with evident symptoms indicative of large bowel obstruction. Abdominal examination revealed distension and rectal examination found a mass mimicking an internal rectal prolapse. Subsequently, imaging studies confirmed the diagnosis of sigmoid-rectal intussusception. The patient underwent an emergency open sigmoid resection with Hartman's procedure. The postoperative course was uneventful. Anatomopathological analysis revealed the presence of stage I adenocarcinoma. A restoration of digestive continuity was scheduled six months later. One-year follow-up assessments showed no indications of local recurrence or distant metastasis.
DISCUSSION
Sigmoid rectal intussusception stands as a unique and infrequently reported medical entity. The absence of distinct clinical symptoms often renders diagnosis a challenging task, with confirmation typically relying on radiological findings. In contrast to the non-surgical approaches employed in pediatric cases, intussusception in adults necessitates surgical intervention due to its predominantly malignant underpinnings.
CONCLUSION
While sigmoid-rectal intussusception is an exceedingly rare occurrence, its manifestation with a multitude of non-specific symptoms can complicate clinical recognition. Nevertheless, it should be duly considered as a potential etiological factor in cases of large bowel obstruction, particularly when suggestive signs are found on rectal examination.
PubMed: 37931504
DOI: 10.1016/j.ijscr.2023.109018 -
Medicine Oct 2023Colonic lipomas are uncommon benign submucosal adipose tumors that are usually asymptomatic. In principle, large lipomas can cause symptoms that require further... (Review)
Review
RATIONALE
Colonic lipomas are uncommon benign submucosal adipose tumors that are usually asymptomatic. In principle, large lipomas can cause symptoms that require further treatment. Here, we report a case of prolapsed giant rectal lipoma and transanal mass resection.
PATIENT CONCERNS
A 65-year-old male developed rectal mass prolapse with bloody stool for 1 day.
DIAGNOSES
The pathological findings were rectal lipoma.
INTERVENTION
After resection of the anal tumor, the patient postoperative symptoms quickly disappeared.
OUTCOMES
No recurrence of the condition was observed after 6 months of follow-up after surgery.
LESSONS
It is safe and feasible for us to perform transanal mass resection for giant rectal lipomas that protrude outside the anus.
Topics: Male; Humans; Aged; Colonic Neoplasms; Colonoscopy; Rectal Neoplasms; Rectal Prolapse; Lipoma
PubMed: 37904353
DOI: 10.1097/MD.0000000000034429 -
Journal of the Anus, Rectum and Colon 2023Stomal prolapse (SP) is one of the most common complications of loop colostomy and can impair a patient's quality of life. Herein, we evaluated the risk factors for SP...
OBJECTIVES
Stomal prolapse (SP) is one of the most common complications of loop colostomy and can impair a patient's quality of life. Herein, we evaluated the risk factors for SP to prevent its occurrence after a transverse loop colostomy.
METHODS
This retrospective study included 84 patients who underwent loop transverse colostomy between January 2016 and December 2020. We evaluated the incidence of SP and examined the relationship between perioperative factors and SP using univariate and multivariate logistic regressions.
RESULTS
SP occurred in 11 (13.0%) patients. Median time to SP was 99 postoperative days. In the univariate analysis, a right side abdominal wall stoma site, perioperative chemotherapy, and anti-VEGF antibody therapy were associated with a significantly higher incidence of SP. Multivariate analysis identified that construction of a temporary loop colostomy in the right transverse colon during rectal cancer surgery (odds ratio, 5.07; 95% confidence interval, 1.12-22.86) is an independent risk factor.
CONCLUSIONS
In this study, multivariate analysis showed that the right side of the transverse colon was a risk factor for SP. Therefore, when constructing a transverse colon loop stoma, the stoma should be constructed in the left transverse colon to prevent SP.
PubMed: 37900692
DOI: 10.23922/jarc.2023-013 -
Cell Reports Nov 2023Intestinal colonization by antigenically foreign microbes necessitates expanded peripheral immune tolerance. Here we show commensal microbiota prime expansion of CD4...
Intestinal colonization by antigenically foreign microbes necessitates expanded peripheral immune tolerance. Here we show commensal microbiota prime expansion of CD4 T cells unified by the Kruppel-like factor 2 (KLF2) transcriptional regulator and an essential role for KLF2+ CD4 cells in averting microbiota-driven intestinal inflammation. CD4 cells with commensal specificity in secondary lymphoid organs and intestinal tissues are enriched for KLF2 expression, and distinct from FOXP3+ regulatory T cells or other differentiation lineages. Mice with conditional KLF2 deficiency in T cells develop spontaneous rectal prolapse and intestinal inflammation, phenotypes overturned by eliminating microbiota or reconstituting with donor KLF2+ cells. Activated KLF2+ cells selectively produce IL-10, and eliminating IL-10 overrides their suppressive function in vitro and protection against intestinal inflammation in vivo. Together with reduced KLF2+ CD4 cell accumulation in Crohn's disease, a necessity for the KLF2+ subpopulation of T regulatory type 1 (Tr1) cells in sustaining commensal tolerance is demonstrated.
Topics: Mice; Animals; CD4-Positive T-Lymphocytes; Interleukin-10; T-Lymphocytes, Regulatory; Transcription Factors; Inflammation; Microbiota; Kruppel-Like Transcription Factors
PubMed: 37889750
DOI: 10.1016/j.celrep.2023.113323 -
Journal of Indian Association of... 2023Anorectal malformations (ARMs) are managed classically in three stages - colostomy at birth, anorectal pull-through after 2-3 months, and stoma closure. Single-stage... (Review)
Review
Anorectal malformations (ARMs) are managed classically in three stages - colostomy at birth, anorectal pull-through after 2-3 months, and stoma closure. Single-stage pull-through has been contemplated in neonatal age aimed to reduce the number of procedures, better long-term continence, the better psycho-social status of the child, and reduced cost of treatment, especially in resource-strained countries. We conducted a systematic review comparing neonatal single-stage pull-through with stage pull-through and did a meta-analysis for the outcome and complications. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. PubMed and Scopus databases were searched and RevMan 5.4.1 was used for the meta-analysis. Fourteen comparative studies including one randomized controlled trial were included in the systematic review for meta-analysis. The meta-analysis included 1845 patients including 866 neonates undergoing single-stage pull-through. There was no statistically significant difference for the occurrence of surgical site infection (odds ratio [OR] 0.82, 95% confidence interval [CI]: 0.24-2.83), urinary tract injury (OR 1.82, 95% CI: 0.85-3.89), rectal prolapse (OR 0.98, 95% CI: 0.21-5.04), anal stenosis/stricture, voluntary bowel movements (OR 0.97, 95% CI: 0.25-3.73), constipation (OR 1.01, 95% CI: 0.61-1.67), soiling (OR 0.89, 95% CI: 0.52-1.51), mortality (OR 1.19, 95% CI: 0.04-39.74), or other complications. However, continence was seen to be better among patients undergoing neonatal pull-through (OR 1.63, 95% CI: 1.12-2.38). Thus, we can recommend single-stage pull-through for managing patients with ARMs in the neonatal age.
PubMed: 37842219
DOI: 10.4103/jiaps.jiaps_28_23