Article

Rectal prolapse: a historical perspective.

Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Mayfield Heights, Ohio, USA.
Current problems in surgery (Impact Factor: 1.42). 09/2009; 46(8):602-716. DOI:10.1067/j.cpsurg.2009.03.006
Source: PubMed
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    ABSTRACT: Aim:  Validated guidelines for the surgical and non-surgical treatment of rectal prolapse (RP) do not exist. The aim of this international questionnaire survey was to provide an overview of the evaluation, follow-up and treatment of patients with an internal or external RP. Method:  A 36 question questionnaire in English about the evaluation, treatment and follow-up of patients with rectal prolapse was distributed amongst surgeons attending the congresses of the European Association for Endoscopic Surgery (EAES) and the European Society of Coloproctology (ESCP) in 2010. It was subsequently sent to all the members of the American Society of Colon and Rectal Surgeons (ASCRS) and the ESCP by email. Results:  Three hundred and ninety one surgeons in 50 different countries completed the questionnaire. Evaluation, surgical treatment and follow-up of patients with RP differed considerably. For healthy patients with an external RP, laparoscopic ventral rectopexy (LVR) was the most popular treatment in Europe, whereas laparoscopic resection rectopexy (LRR) was favored in North America. There was consensus only on frail and/or elderly patients with an external prolapse, with a preference for a perineal technique. After failure of conservative therapy, internal RP was mostly treated by LRR in North America. In Europe, LVR and stapled transanal rectal resection (STARR) were the most popular techniques for these patients. Conclusion:  The treatment of RP differs between surgeons, countries and regions. Guidelines are lacking. Prospective comparative studies are warranted that may result in universally accepted protocols. © 2012 The Authors Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.
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    ABSTRACT: Laparoscopic ventral rectopexy (LVR) is an established technique for the treatment of rectal prolapse. Several techniques and devices can be used for proximal mesh fixation on the sacral promontory during this procedure. The aim of this study was to compare the fixation strength of a recently introduced screw for mesh fixation on the promontory during LVR with two other frequently used techniques. An ex vivo experimental model using a porcine spinal column was designed to measure the strength of proximal mesh fixation. In a laparoscopic box trainer, a polypropylene mesh was anchored on the spinal column using three different fixation methods, i.e., the Protack 5-mm tacker device, Ethibond Excel 2-0 stitches, and the Karl Storz screw. Subsequently, increasing traction was applied to the mesh. This traction was applied at a standardized angle as determined by measuring the mean angle between the site of distal mesh fixation on the rectum and a line straight through the sacral promontory on 12 random dynamic MR scans of the pelvic floor after the LVR procedure. The applied force was measured at the moment that the fixation broke, using a calibrated electronic Newton meter. All fixation methods were tested ten times. The mean angle, as measured on the MR scans, was 100°. The mean disruption force, which led to a break of the proximal mesh fixation, was 58 N for the three Protack tacks, 55 N for the two stitches, and 70 N for the new screw. The use of a screw therefore led to a significantly stronger fixation compared to the use of stitches (p ≤ 0.05). No significant difference was determined between the tacks and the screw fixation and between the tacks and the stitches fixation. The new screw for proximal mesh fixation during LVR procedures offers similar fixation strength when compared to tacks. The use of one screw for proximal mesh fixation is therefore a reasonable alternative to the use of several tacks or sutures.
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James S Wu