Ventral Rectopexy is a good treatment for total rectal prolapse-Prof. Michael Thompson

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 Proceedings of Surgical Week for Colorectal Diseases at JPMC-II

Ventral Rectopexy is a good treatment for total
rectal prolapse - Prof. Michael Thompson

Delorme’s procedure is treatment of choice in frail
patients 
and people with defaecatory disorders

Defecating Proctogram provides structural as well as
functional information - Vaqar Bari

KARACHI: On Third day of the Surgical Week for colorectal diseases held at JPMC from October 9-12, 2017, Prof. Michael Thompson talked about Laparoscopic Ventral Rectopexy. He pointed out that now daycare Ventral Rectopexy is achievable. It is a good treatment for total rectal prolapse. However, he warned that though mesh repair has good results and it is well tolerated with low recurrence rate but in1990s, there were reports of infected mesh which must be kept in mind. Recurrence with Rectopexy is between 7-31% and some severe complications are noted much later.

Prof. Thompson then gave results of UK Prosper Rectal Prolapse Trial which enrolled 293 patients. It was a multicenter trial which lasted seven years. The overall mortality was 1.7%.So we have no answer as to which procedure is the best but LVR is promising but it was too early to make firm decision. During the discussion it was pointed out that beware of new operations. Biological mesh results are good so far. Age of the patient matters while deciding which operation to perform. For elderly patients Vent Rectopexy may not be a good operation which is good for young patients.

Prof. Vaqar Bari talked about Defecating Proctogram which provides structural as well as functional information.  It is known as defecography or evacuation proctography. He was of the view that one must ensure appropriate indication for this test only then it will be helpful. Some of the indications are constipation, incomplete evacuation.  With relaxation of muscle the rectum is in line with anal canal and it allows evacuation. Ano rectal angle, he stated, was important. Usually it is at ninety degree but it increases at the time of defecation. Fecal incontinence should be labelled only if it is there for some time and one should not label it immediately. Studies have showed its prevalence in United States of 18.4%.These patients have incontinence at rest, at squeeze or when they cough. Patient cannot stop it. Most rectoceles are in females, anterior is most common but posterior is rare. These rectoceles retain fecal matter.

Speaking about contra indications for MR Defecography he mentioned that patients who are non-compliance are not good candidates. Other contra indications include non-communicating rectum, suspected perforation. Its limitations include low resolution, single plane and radiation. Open MR has some advantages. Study can be performed in sitting posture. Preparation of the patient for MR Defecography, Dr. Bari stated takes ten to fifteen minutes but the study can be performed in just two to three minutes once the patient is seated on commode.

It was followed by live surgery demonstrated by Prof. Holm from Sweden. His advice to the surgical colleagues was not to operate too quickly though the young colleagues and nurses appreciate those who do quick surgery. However, what they are doing or they have done is known later.  Prof. Holm opined that the surgeon should take his time to do surgery. Responding to a question he said that he had limited experience of rectal prolapse surgery. Recurrence is there in various procedures. Recurrence after second operation is faster. Repeat Delorme’s procedure is easy. He further stated that putting mesh in young patients is not good. Prof. Abul Fazal from Lahore participating in the discussion stated that we take consent from the patient to do any procedure which is necessary and needed during surgery.

Delrome’s Procedure for Rectal Prolapse

Prof. Michael Thompson’s next presentation was on Delrome’s procedure in Rectal Prolapse. He pointed out that it was Edmond Delorme who did this procedure on three young male soldiers in 1900.Out of these two had good results while one patient died. Mortality in collected Delorme’s procedure is about 2% in a series of 250 cases while in collected abdominal procedures mortality was 0-3%. Mortality is high in elderly patients. He also referred to colonic leak, rectal prolapse anastomosis leak and learning curve of the surgeons. Though both the procedures are currently being performed but Rectopexy was more popular in UK. Delorme’s has varying recurrence rates. A major factor is completeness and length of follow up. Berman in 1985-1990 used the Delorme’s procedure as a treatment for constipation. Delmore decreases constipation because of low rectal compliance and volume and rectum being more sensitive. It results in improved evacuation. Removal of colonic break also improves rectal filling.  In a series of 81 cases, 89% of patients were either static or showed improvement.  A study published in Indian Journal of Surgery by Mahmood et all showed that Delorme’s procedure is treatment of choice in frail patients and people with defaecatory disorders. Another study showed 5% morbidity and 5% mortality with Altemeier’s procedure in twenty cases with two to five years of follow up. The authors also reported 90% improvement in incontinence functions. Delrome’s has higher recurrence rate as compared to Altemeier’s anastomotic leak rate and pelvic sepsis.

He concluded his presentation by stating that one should consider Delorme or Altemeier’s first, when it recurs   consider a redo although it is likely to recur more quickly. In younger patients consider a laparoscopic abdominal procedures for recurrence. Avoid invasive procedures in frail elderly patients. He further suggested that one should avoid or postpone a fertility/sexual functioning threatening operation in young patients.  Delivery of health care and what surgeons can do and the volume of work is very important. We also need to know more about the long term effects of a ventral pelvic mesh, he remarked.