Chapter 11.6
Outcomes After Laparoscopic Treatment for Rectal Prolapse
Jeffrey W. Milsom, Bartholomäus Böhm, and Kiyokazu Nakajima
Rectal prolapse is a rare disease but can usually be cured by surgery.
Many abdominal and perineal approaches have been described in the past. Currently, abdominal surgery with some type of rectopexy plus or minus sigmoid resection is the most common abdominal operation to treat rectal prolapse. Because different opinions about the best avail- able procedure are well known and the debate is unsettled, this chapter only discusses whether the laparoscopic approach is benefi cial com- pared with the conventional approach if an abdominal procedure is chosen to treat the prolapse.
Methods
Search of Literature
The literature database MEDLINE was searched for all clinical studies for the years 1993–2004. The MeSh-terms “rectal prolapse,” “recto- pexy,” “laparoscopy*,” and “laparoscopic surgery*” were used for the search and more than 100 publications written in English were found.
Laparoscopic, laparoscopic-assisted, and hand-assisted procedures were included. Clinical studies including patients with other diseases, studies reported in multiple publications, small case series with less than 18 patients, or data given only as abstracts were excluded from further analysis.
Outcomes
The studies were carefully analyzed and the following items extracted if given: Morbidity, mortality, the proportion of conversion to a con- ventional approach, the duration of surgery, time to fi rst fl atus, time to resumption of a regular diet, and the length of postoperative hospital stay. All endpoints were looked at in the comparative cohort studies, summarized in an “intent-to-treat” analysis, and compared between laparoscopic and conventional surgery. If long-term results were avail- able, the length of follow-up and recurrence rate were documented.
370
Data Analysis
The overall quality of the studies would be classifi ed as level of evi- dence 3–5. Most of the studies we found were very small retrospective or prospective case series which were excluded from this analysis.
There is only one randomized controlled trial (RCT) that compared both laparoscopic and open approaches in patients with rectal pro- lapse.1 A second publication was written on the same trial to eva- luate the economic impact.2 This RCT and three comparative cohort studies3–5 were analyzed (Table 11.6.1).
Results
The RCT1 described a longer operative time, shorter hospital stay, and quicker resumption of liquid and normal diet. No conversion was required. The stress response (IL-6, CRP, and catecholamine) was more pronounced after conventional surgery. The morbidity was 3/20 in the laparoscopic group and 9/19 in the conventional group (P= .03). The economic analysis showed that the mean hospital costs were £2812 in the laparoscopic group and £3169 in the conventional group. The dif- ference was £357 [95% confi dence interval (CI): £164 to £592]. This advantage of the laparoscopic approach is attributed to the longer hospital stay. The costs in the operating room are higher in the laparo- scopic group.
Table 11.6.1. Method of the comparative cohort studies on rectal prolapse
Author Period (months) n Rate Solomon et al.1 36 39 1.1 RCT.
Kairaluoma et al.5 90 56 0.6 Fifty-six laparoscopic
procedures were compared with 56 historical controls which were retrospectively analyzed.
Xynos et al.10 – 18 –
Ten laparoscopic procedures were
compared with 8 historical controls. The observational period was not given.
Baker et al.4 54 18 0.3
Laparoscopic approach was compared with historical
controls.
The length of the study in months (period) and number of resections (n) was given to calculate the resection rate per month (rate).
The comparative studies and RCTs prove that operative time is about 65 minutes longer (Table 11.6.2; Figure 11.6.1) and hospital stay 2 days shorter (Figure 11.6.2). Morbidity may also be less after laparoscopic surgery (Figure 11.6.3).
Discussion
Whereas the perineal approach (perineal resection or the Delorme procedure) is usually performed in elderly or high-risk patients, the abdominal approach is generally preferred in otherwise healthy patients because of the lower incidence of recurrence.
Different abdominal procedures have been recommended to cure rectal prolapse. Madbouly et al.6 described good results after laparo- scopic Wells procedure (n = 13) and sutured rectopexy with resection (n= 11). The Wells procedure needed less operative time and shorter hospital stay.
The long-term results are overall acceptable. Stevenson et al.7 reported on no full thickness recurrence after 18 months (n = 26), Kessler et al.8 on 2/32 recurrence after 33 months, and Bruch et al.9 on 0/53 recur- rences after 30 months.
Table 11.6.2. Comparison of outcomes of all comparative studies (n= 5) for rectal prolapse
Statistical Effect
Outcome Studies Patients method size Operative time 4 181 WMD 65.54 (min) (random), [46.77,
95% CI 84.31]
Hospital stay 4 181 WMD -2.00 (days) (random), [-3.91,
95% CI -0.08]
Morbidity 4 181 RR 0.58 [0.30,
(random), 1.13]
95% CI
WMD, weighted mean difference; CI, 95% confi dence interval; RR, risk ratio.
Figure 11.6.1. Operative time [weighted mean difference (WMD) including the 95% CI] after laparo- scopic and conventional surgery for rectal prolapse.
Review: Rectal prolapse Comparison: 01 Operative time Outcome: 01 Operative time
Study Laparoscopic group Conventional group WMD (random)
or sub-category N Mean (SD) N Mean (SD) 95% Cl
Baker et al. 8 177.00 (23.00) 10 87.00 (9.00)
Xynos et al. 10 130.00 (32.00) 8 80.00 (25.00)
Solomon et al. 20 153.00 (20.00) 19 102.00 (20.00)
Kairalouma et al. 53 170.00 (50.00) 53 101.00 (30.00)
Total (95% Cl) 91 90
Test for heterogeneity: Chix= 14.68, df = 3 (P = 0.002), lx= 79.6%
Test for overall effect: Z = 6.84 (P < 0.00001)
-100 -50 0 50 100
Favours laparoscopic Favours conventional
Conclusion
In conclusion, laparoscopic surgery for rectal prolapse also seems to be safe with good long-term results. Whether there are advantages over the open method or whether morbidity is really lower has to be proven in further studies.
Final Questions for Consideration
1. Is the laparoscopic approach associated with less morbidity?
Likely (Recommendation C).
2. Does the laparoscopic approach lead to less mortality?
No (Recommendation C).
Figure 11.6.2. Hospital stay [weighted mean difference (WMD) including the 95% CI] after laparo- scopic and conventional surgery for rectal prolapse.
Figure 11.6.3. Morbidity [risk ratio (RR) including the 95% CI] after laparoscopic and conventional surgery for rectal prolapse.
Review: Rectal prolapse Comparison: 02 Hospital stay Outcome: 01 Hospital stay
Study Laparoscopic group Conventional group WMD (random)
or sub-category N Mean (SD) N Mean (SD) 95% Cl
Baker et al. 8 4.00 (0.80) 10 2.90 (0.40)
Xynos et al. 10 4.70 (1.10) 8 8.30 (1.90)
Solomon et al. 20 3.90 (0.50) 19 6.60 (2.00)
Kairalouma et al. 53 5.00 (4.30) 53 7.00 (5.00)
Total (95% Cl) 91 90
Test for heterogeneity: Chix= 38.39, df = 3 (P < 0.00001), lx= 92.2%
Test for overall effect: Z = 2.05 (P = 0.04)
-10 -5 0 5 10
Favours laparoscopic Favours conventional
Review: Rectal prolapse Comparison: 03 Morbidity Outcome: 01 Morbidity
Study Laparoscopic group Conventional group RR (random)
or sub-category n/N n/N 95% Cl
Baker et al. 1/8 0/10
Xynos et al. 1/10 3/8
Solomon et al. 3/20 9/19
Kairalouma et al. 12/53 16/53
Total (95% Cl) 91 90
Total events: 17 (Laparoscopic group), 28 (Conventional group) Test for heterogeneity: Chix= 3.58, df = 3 (P = 0.31), lx= 16.1%
Test for overall effect: Z = 1.61 (P = 0.11)
0.1 0.2 0.5 1 2 5 10 Favours laparoscopic Favours conventional
3. What are the short-term advantages to the laparoscopic approach?
Hospital stay is shorter and morbidity is lower (Recommendation C).
4. Does the laparoscopic approach increase hospital costs?
No (Recommendation B).
5. Are the long-term results in favor of the laparoscopic approach?
Not known because no comparative studies have addressed the long-term results (Recommendation D).
References
1. Solomon MJ, Young CJ, Eyers AA, et al. Randomized clinical trial of lapa- roscopic versus open abdominal rectopexy for rectal prolapse. Br J Surg 2002;89:35–39.
2. Salkeld G, Bagia M, Solomon M. Economic impact of laparoscopic versus open abdominal rectopexy. Br J Surg 2004;91:1188–1191.
3. Xynos E, Chrysos E, Tsiaoussis J, et al. Resection rectopexy for rectal pro- lapse. The laparoscopic approach. Surg Endosc 1999;13:862–864.
4. Baker R, Senagore AJ, Luchtefeld MA. Laparoscopic-assisted vs. open resection. Rectopexy offers excellent results. Dis Colon Rectum 1995;
38:199–201.
5. Kairaluoma MV, Viljakka MT, Kellokumpu IH. Open vs. laparoscopic surgery for rectal prolapse: a case-controlled study assessing short-term outcome. Dis Colon Rectum 2003;46:353–360.
6. Madbouly KM, Senagore AJ, Delaney CP, et al. Clinically based manage- ment of rectal prolapse. Surg Endosc 2003;17:99–103.
7. Stevenson AR, Stitz RW, Lumley JW. Laparoscopic-assisted resection- rectopexy for rectal prolapse: early and medium follow-up. Dis Colon Rectum 1998;41:46–54.
8. Kessler H, Jerby BL, Milsom JW. Successful treatment of rectal prolapse by laparoscopic suture rectopexy. Surg Endosc 1999;13:858–861.
9. Bruch HP, Herold A, Schiedeck T, et al. Laparoscopic surgery for rectal prolapse and outlet obstruction. Dis Colon Rectum 1999;42:1189–1194.
10. Xynos E, Chrysos E, Tsiaoussis J, et al. Resection rectopexy for rectal pro- lapse. The laparoscopic approach. Surg Endosc 1999;13:862–864.
