Long-Term Functional Outcomes After Laparoscopic and Open Rectopexy for the Treatment of Rectal Prolapse ORIGINAL CONTRIBUTION

Christopher M. Byrne, M.B.B.S.(Hons.), B.Sc.(med.), M.S., F.R.A.C.S.1  Steven R. Smith, M.B.B.S., B.Sc.(med.), M.S., F.R.A.C.S.2  Michael J. Solomon, M.B.B.Ch.(Hons.), M.Sc.(Cl. Epid.), F.R.A.C.S.1,3  Jane M. Young, Ph.D., M.P.H., M.B.B.S., F.A.F.P.H.M.3  Anthony A. Eyers, M.B.B.S., M.Bioethics, F.R.C.S., F.R.A.C.S.1  Christopher J. Young, M.B.B.S., M.S., F.R.A.C.S.1 1 Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia 2 Department of Surgery, John Hunter Hospital, Newcastle, Australia 3 Surgical Outcomes Research Centre (SOuRCE), University of Sydney & Royal Prince Alfred Hospital, Newtown, Australia

PURPOSE: Laparoscopic rectopexy to treat full-thickness

rectal prolapse has proven short-term benefits, but there is little long-term follow-up and functional outcome data available. METHODS: Patients who had abdominal surgery for

prolapse during a ten-year period were identified and interviewed to ascertain details of prolapse recurrence, constipation, incontinence, cosmesis, and satisfaction. Additional details on recurrences that required surgery and mortality were obtained from chart review and the State Death Registry. RESULTS: Of 321 prolapse operations, laparoscopic recto-

pexy was performed in 126 patients, open rectopexy in 46, and resection rectopexy in 21 patients. At a median followup of five years after laparoscopic rectopexy, there were five (4 percent) confirmed full-thickness recurrences that required surgery. Actuarial recurrence rates of laparoscopic rectopexy were 6.9 percent at five years (95 percent confidence interval, 0.1–13.8 percent) and 10.8 percent at ten years (95 percent confidence interval, 0.9–20.1 percent). Seven patients underwent rubber band ligation for mucosal prolapse and seven required other surgical procedures. There was one recurrence after open rectopexy (2.4 percent) and one after resection rectopexy (4.7 percent), and there was no significant difference between groups. Overall constipation scores were not increased after laparoscopic Dr. Byrne was supported by the Notaras Fellowship from the University of Sydney, the Scientific Foundation of the Royal Australasian College of Surgeons and the training board of the Colorectal Society of Australasia. Presented at the Tripartite Colorectal meeting, Dublin, Ireland, July 5 to 7, 2005. Reprints are not available. Address of correspondence: Professor Michael Solomon, Royal Prince Alfred Medical Centre, 415/100 Carillon Avenue, Newton, NSW 2042, Australia. E-mail: [email protected]

rectopexy, with no significant difference to open rectopexy or resection rectopexy. CONCLUSIONS: This study has demonstrated that laparoscopic rectopexy has reliable long-term results for treating rectal prolapse, including low recurrence rates and no overall change in functional outcomes. KEY WORDS: Laparoscopy; Rectal prolapse; Treatment

outcomes.

ull-thickness rectal prolapse (FTRP) is the complete protrusion of the rectum through the anal canal.1 There are many procedures described for the treatment of rectal prolapse, which can be divided into abdominal or perineal approaches. The perineal approach has been reserved for the frail and elderly as a general anesthetic and laparotomy incision can be avoided, whereas the abdominal approach is thought to provide a more robust repair with a lower recurrence rate.2,3 An abdominal approach usually involves a rectopexy, with or without resection of the sigmoid colon. More recently, laparoscopic surgery has emerged as a tool for the treatment of FTRP, and in particular is well suited for fixation rectopexy, because no specimen is removed and no anastomosis is required. Previous trials have suggested that laparoscopic rectopexy (LR) is superior to open rectopexy (OR) with regard to most short-term outcomes,4–6 but data are sparse regarding the longer-term outcomes after LR. In particular there are limited data comparing long-term functional outcomes after fixation or resection rectopexy.2,3 An historic, controlled trial and subsequent prospective, randomized, clinical trial performed at Royal Prince Alfred Hospital found significant differences in favor of LR compared with OR with regard to the short-term outcomes of pain, narcotic requirements, mobility, morbidity, and length of stay; operative time was the only outcome that

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DOI: 10.1007/s10350-008-9365-6  VOLUME 51: 1597–1604 (2008)  ©THE ASCRS 2008  PUBLISHED ONLINE: 29 AUGUST 2008

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favored OR.7 There was no difference found in the mediumterm outcomes of recurrence, incontinence, and constipation during the follow-up period of 24 months, and consequently standard practice at our institution is to perform laparoscopic fixation rectopexy for FTRP when an abdominal operation has been chosen. The primary goal of this study was to perform an audit of a single-center experience with LR with focus on the longer-term outcomes of prolapse recurrence, further interventions, and functional outcomes, including incontinence and constipation rates and satisfaction. The secondary goal of this study was to compare the long-term functional outcomes between LR and the other abdominal rectopexies performed during the same period. Last, a subgroup analysis of the long-term outcomes from the randomized, controlled trial of LR vs. OR was planned.

PATIENTS AND METHODS All patients who had undergone procedures for FTRP performed by colorectal surgeons at Royal Prince Alfred Hospital were identified from a prospectively maintained clinical database, during a ten-year period from June 1994 to June 2004. From 1994 to 1995, 21 LR procedures were performed at RPAH as part of an historic cohort study.4 After this, 40 patients were recruited into a randomized, controlled trial of LR vs. OR.7 All subsequent patients with FTRP deemed suitable for an abdominal procedure after the completion of this trial in December 1999 were offered LR. Patients with intractable constipation preceding the development of FTRP were advised to undergo resection rectopexy (RR). The surgical technique in the early 1990s for laparoscopic rectopexy involved an umbilical camera port with five 10 mm operating ports. Improvements in technique after the initial trial resulted in reducing the operating ports to three (1×12 mm, 2×5 mm). Full circumferential rectal mobilization to the level of the anorectal junction was performed by using diathermy dissection. The “lateral ligaments” were routinely divided. A posterior incomplete offset polypropylene mesh wrap was secured with staples to both the sacral promontory and lateral rectum.4 Sacral fixation went from a custom 12 mm Richards chromium staple4 to the option of multiple 5 mm Protack staples (Autosuture™ Pty Ltd, Sydney, NSW, Australia) for the last five years. Long-term results were obtained from telephone interviews of participants who had undergone abdominal rectopexy for FTRP at least two years before the interview. Ethics approval obtained covered only those patients operated on in the public hospital (RPAH). The other patients operated on at six other institutions comprised <15 percent of the total number of patients. All eligible patients identified from the database were cross-checked against the records of the New South Wales Registry of Births, Deaths and Marriages to identify those who had died, and re-

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maining eligible patients were mailed a letter by their treating specialist asking them to participate in a telephone interview. A reminder letter and a single phone call were used to follow-up nonresponders. Referring general practitioners were contacted to ascertain the date of last follow-up and whether there had been documented recurrence of rectal prolapse.

OUTCOME MEASURES Telephone interviews were conducted by one of two research nurses or a colorectal surgeon using a 65 question pro forma that took an average of 30 minutes to complete. The interviewers were blinded to the type of operation that had been performed. Recurrence was assessed during the interview by asking patients whether they had symptomatic recurrence as well as asking whether they had seen a doctor or had further prolapse surgery and also by asking whether they had to push a lump back into their anus. Patients who reported recurrence of prolapse were cross-checked with follow-up details from the surgeon’s notes to determine whether they had FTRP or simply mucosal prolapse. Recurrence was defined as a full-thickness recurrence documented by a surgeon or an operation performed at any institution for mucosal or full-thickness recurrence (with the exception of rubber band ligation of mucosal prolapse). Incontinence was assessed by using the St. Mark’s incontinence score described by Luniss et al.8 (0=no incontinence to 13=complete incontinence). Current medication use and constipation rates were assessed via a series of categorical questions, asking specifically about laxative, enema, and medication use, frequency and type of bowel motions, and frequency of straining and incomplete evacuation using a questionnaire based on Section D of the Rome III criteria.9 Preoperative and postoperative Visual Analog Scores (VAS), along with a five-point Likert scale were used to assess constipation Using a five-point Likert scale, patients were asked to scale their constipation from “much worse” to “much better.” Satisfaction with surgery was assessed using a five-point Likert scale. Statistical Analysis All data was entered into SPSS version 12.0.1 (SPSS® Inc., Chicago, IL). Differences in proportions were compared with chi-squared test and Fisher’s exact test where appropriate. Changes in continuous outcomes between groups were compared using independent Student’s t-tests or the appropriate nonparametric equivalent A recurrence analysis using Kaplan-Meier method was performed using SAS® version 9.1 (SAS Institute Inc., Cary, NC). Patients who died or were lost to follow-up were censored at the time of death or last clinical follow-up. Comparison of each operation’s recurrence-free interval was performed using the log-rank method.

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RESULTS During the ten-year study period, 321 patients were treated by four colorectal surgeons for FTRP. There were 128 perineal procedures (99 Delormes and 29 perineal proctosigmoidectomies) and 193 abdominal procedures comprising 126 LR patients, 46 OR, and 21 RR. Long-Term Outcomes Prolapse Recurrence and Further Surgery. Of 126 LR patients, there were 5 confirmed FTRP recurrences that required surgery, giving a crude recurrence of 4 percent. Cross-checking records and interviews with outside clinicians confirmed a further seven (5.5 percent) that required surgery for other indications (i.e., not FTRP) and seven that required banding of mucosal prolapse (5.5 percent). Table 1 summarizes patients who required further procedures. Seven additional patients underwent banding of mucosal prolapse at a median of ten (range, 1– 24) months. At interview, another five patients thought that they had rectal prolapse, two patients did not have recurrent prolapse after clinical examination, and three patients had not sought any medical assessment. Thus, a total of 17 patients thought that they had recurrence, although only five of them actually had recurrent FTRP. The mean age of the 126 patients was 56.2 years with a median follow-up of 5 years. The median time to reoperation in the LR group was 12 (range, 3–40) months (Table 1). Of 21 RR, 1 patient recurred after three years and underwent a redo resection rectopexy, and 3 others required

banding of mucosal prolapse. Of 46 OR, there was 1 FTRP that recurred within four months and was treated by perineal proctosigmoidectomy, and another 2 patients who had anal mucosal prolapse treated by banding. One additional patient in this group underwent an anterior levatorplasty for intractable fecal incontinence. The time to reoperation in the OR group was 5 months and the time to repeat mucosal banding was 24 (range, 6–36) months. Actuarial recurrence rates for LR were 6.9 percent at five years (95 percent confidence interval (CI), 0.1–13.8) and 10.8 percent at ten years (95 percent CI, 0.9–20.1). Five-year actuarial recurrence rates for RR and OR were 11.8 percent (95 percent CI, 0–13.8) and 3.2 percent (95 percent CI, 0– 9.4), respectively. The ten-year rates were identical to the five-year rates as a result of no additional recurrence in either group, and therefore, caution should be exercised in interpreting these results given the low power. There was no significant difference between recurrence rates and the type of operation (chi-squared=1.81, df (degrees of freedom)=2, P=0.4), gender (chi-squared=0.01, df=1, P=0.9) or age group (chi-squared=1.81, df=2, P=0.4). The recurrence-free curves are displayed in Figure 1. Functional Outcomes A total of 83 LR patients were eligible for the purpose of long-term follow-up by telephone interview (as covered by RPAH ethics approval). Eight of 83 were deceased, 21 were not contactable, and 8 declined to be interviewed, leaving 46 patients (61 percent) who participated in an interview that assessed long-term functional results at a median of 61 months after the procedure. Fourteen of 21 RR (66

Table 1. Patients who required repeat procedures on long-term follow-up after abdominal surgery for full-thickness rectal prolapse

Sex/Age (yr)

Subsequent procedure

Laparoscopic rectopexy (n=126) F57 Zacharins procedure F52 Multiple – graciloplasty, anterior resection and ultimately sigmoid colostomy M73 Delormes procedure F84 Delormes procedure x 3 F56 Laparoscopic resection rectopexy F26 Laparoscopic resection rectopexy F55 Laparotomy/removal mesh F83 Anterior Delormes procedure F60 Stapled hemorrhoidectomy F63 Laparoscopic sigmoid colostomy F40 Laparoscopic anterior resection F54 Laparoscopic anterior resection Open rectopexy (n=46) F60 Perineal proctosigmoidectomy F68 Anterior levatorplasty Resection rectopexy (n=21) F75 Resection rectopexy

Indication

Time after initial surgery (mo)

Full-thickness rectal prolapse Ongoing incontinence then full-thickness rectal prolapse

10 12

Full-thickness rectal prolapse Full-thickness rectal prolapse Full-thickness rectal prolapse

36 4 40 12 3

Intra-abdominal sepsis from continuous ambulatory peritoneal dialysis (end stage renal failure) Anterior mucosal prolapse Circumferential anal mucosal prolapse Ongoing incontinence Constipation – segmental slow transit Constipation – segmental slow transit

3 12 36 34 8

Full-thickness rectal prolapse Ongoing incontinence

4 6

Full-thickness rectal prolapse

48

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0.9

Group = Lap Rectopexy Group = Open Rectopexy Group = Resection Rectopexy Censored Group = Lap Rectopexy Censored Group = Open Rectopexy Censored Group = Resection Rectopexy

0.7

0.6

0

20

40

60 80 100 Time to Recurrence (Months)

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LONG -TERM OUTCOMES A FTER R ECTOPEXY

nence with a structurally normal sphincter, and 4) a patient who underwent an anterior levatorplasty who had an anterior sphincter defect. There were no significant differences between the three groups in terms of their incontinence scores at long-term follow-up (F=0.39, df=2, P=0.68).

Survival Distribution Function 1.0

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FIGURE 1. Recurrent prolapse-free curves stratified by operation type.

percent) were interviewed at a mean of 65 months after the procedure and 23 of 36 OR (77 percent) were interviewed at a mean of 82 months after the procedure. Table 2 summarizes the follow-up of the groups eligible for functional outcomes (Tables 2, 3 and 4). Continence Scores The mean St. Mark’s incontinence scores improved compared with preoperative scores from 6.6 to 3.4 for LR and 7.8 to 3.6 for OR (Table 3). The median incontinence score was 3 of 13 with 80 percent of LR patients having a score of ≤7. There was a wide variety of scores from 0 (no incontinence) to 11 (severe incontinence) of 13. Most patients reported some incontinence to gas, and if this component was removed from the score, three-quarters of patients had a score of ≤3. As noted above, several patients with severe ongoing incontinence required various treatments: 1) a patient with a levatorplasty before LR and an anatomically deficient, deinnervated sphincter who underwent stimulated graciloplasty, 2) a permanent defunctioning stoma after prolapse recurrence, 3) a patient who underwent permanent defunctioning stoma for “neuropathic” inconti-

Constipation There was no significant difference in constipation scores compared preoperatively with the present or between groups (Table 3). Specifically, the mean score of LR patients was 4.2 preoperatively and 4.3 at follow-up (t=−0.41, df= 45, P=0.97). Mean score of OR was 4.4 before surgery and 4.9 at follow-up (t=1.27, df=22, P=0.21) and RR was 4.6 preoperatively and 4.6 at follow-up (t=0.31, df=14, P= 0.98). There were no significant differences between the surgical groups (F=0.25, df=2, P=0.78). However, 39 percent of LR patients rated that their symptoms had improved postoperatively, whereas 35 percent rated their symptoms “worse” or “much worse.” Near identical proportions of OR were improved or worse (42 and 35 percent, respectively). Of RR, 36 percent rated themselves better, 28 percent no change, and 36 percent rated themselves worse. In terms of bowel function, >70 percent of all surgical patients used their bowels at least once per day. One-quarter used their bowels every second or third day, and only four or five percent of patients used their bowels weekly or less often. Slightly more patients who had undergone RR reported preoperative constipation (44 percent compared with 30 percent of LR and 32 percent of OR patients). Of note, 53 percent LR, 73 percent OR, and 50 percent of RR used laxatives on a daily or weekly basis. The functional results regarding constipation are summarized in Table 4. Cosmesis The mean rating of cosmesis on a visual analog scale was 0.9 (LR), 1.8 (OR), and 0.5 (RR), which was not significantly different (F=1.66, df=2, P=0.19). Eight of 46 LR thought that their scars were quite “noticeable” compared with 9 of 23 OR patients (chi-squared=3.9, df=1, P=0.05). Ten of 46 LR found their scars “painful” or “itchy” compared with 6 of 23 OR (chi-squared=0.16, df=1, P=0.69). There was one patient who developed a port-site hernia after LR. Two of

Table 2. Details of participation in telephone interview assessing long-term functional outcomes by surgical group

Group

Number

Dead

Lost to follow-up

Refused

Lap fixation Open fixation Resection Total

83 36 21 139

8 (9) 6 (17)

21 (28) 4 (13) 7 (34) 32 (23)

8 (11) 3 (10)

14 (9)

Data are numbers with percentages in parentheses.

11 (8)

Interviewed (% eligible) 46 23 14 83

(61) (77) (66) (66)

Mean age at interview (yr)

Median follow-up (mo)

57 64 66

61 82 65

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Table 3. Long-term functional outcomes from surgery for full-thickness rectal prolapse

Laparoscopic rectopexy (n=46)

Open rectopexy (n=31)

St. Mark’s continence scores (mean values, 0=perfect, 14=severe incontinence) Preoperative incontinence score (0–14) 7 8.1 Current incontinence score (0–14) 3.4 3.6 t-test values (preoperative vs. current) t=2.7, df=45, P<0.01 t=2.92, df=22, P<0.01 Visual Analog constipation score (mean values, 0=none, 10=worst) Preoperative constipation scores (0–10) 4.2 4.4 Current constipation scores (0–10) 4.3 4.9 t-test values (preoperative vs. current) t=−0.41, df=45, P=0.97 t=1.27, df=22, P=0.21 Perceived change in constipation after surgery Improvement in constipation 18 (39) 13 (42) No change 12 (26) 6 (19) Deterioration in constipation 16 (35) 12 (35) Sexual function Sexually active preoperatively 31 (67) 15 (50) Sexually active now 28 (61) 8 (27) Sexual dysfunction 7 (15) 2 (7)

Resection rectopexy (n=14) 4.3 n/a 4.6 4.6 t=0.31,df=14, P=0.98 5 (36) 4 (28) 5 (36) 9 (64) 7 (50) 1 (7)

Data are numbers with percentages in parentheses unless otherwise indicated

the six patients who underwent additional abdominal procedures after LR developed incisional hernias associated with those procedures There were two incisional hernias after OR and none after RR. Ten LR patients (22 percent) had developed urinary or bladder problems in the period since their operation compared with six OR (29 percent) and three RR (25 percent) patients. Eight LR patients (16 percent) had developed sexual problems in the period since surgery

compared with one RR (8 percent) and two OR (10 percent) patients (Table 4). Seven of these ten reported dysperunia, which in most cases began immediately or within three months of surgery. Overall satisfaction with surgery was high; 73 percent of LR were “very happy” or “happy” with the overall outcome of their surgery compared with 82 percent of OR and 75 percent of RR patients. Of the LR patients, 82 percent would have the same operation again and 91 percent stated that

Table 4. Functional outcomes from rectopexy surgery in terms of constipation symptoms

Laparoscopic rectopexy (n=46)

Open rectopexy (n=31)

Resection rectopexy (n=14)

13 (30) 18 (41) 12 (27) 1 (2)

9 (29) 12 (39) 7 (23) 3 (10)

4 (29) 6 (43) 4 (29) -

15 (33) 9 (20) 2 (5) 19 (42)

16 (53) 6 (20) 1 (3) 7 (23)

5 2 1 6

(36) (14) (7) (43)

14 (31) 12 (27) 11 (24) 8 (18)

11 (36) 14 (45) 3 (10) 3 (10)

4 4 2 3

(31) (31) (15) (23)

10 (22) 13 (28) 6 (13) 17 (37)

7 (23) 12 (38) 4 (13) 8 (26)

4 (31) 2 (15) 1 (8) 6 (46)

15 (33) 10 (22) 6 (13) 15 (33)

16 (52) 8 (26) 2 (6) 5 (16)

8 (57) 1 (7) 3 (21) 2 (14)

Bowel frequency >Daily Daily Every second or third day Weekly Laxative use Daily More than once per week Weekly or monthly Never Pass hard bowel motions Daily More than once per week Weekly or monthly Never Straining to evacuate Daily More than once per week Weekly or monthly Never Incomplete evacuation Daily More than once per week Weekly or monthly Never Data are numbers with percentages in parentheses.

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Table 5. Long-term functional outcomes from randomized, controlled trial of laparoscopic vs. open rectopexy for full-thickness rectal prolapse

Laparoscopic resection (n=12) St. Mark’s continence scores (0=perfect, 14=severe incontinence) Preoperative incontinence score (0–14) Incontinence score at 2 years (0–14) Current incontinence score (0–14) Visual Analog Constipation Score (0=none, 10=worst) Preoperative constipation scores (0–10) Constipation score at 2 years (0–14) Current constipation scores (0–10) Perceived change in constipation after surgery Improvement in constipation No change Deterioration in constipation

Open resection (n=10)

6.6 1.6 3

7.8 2 2.8

2.4 2.9 4.2

2.4 2.4 4.2

7/12 (58) 2/12 (17) 3/12 (25)

6/10 (60) 2/10 (20) 2/10 (20)

Data are numbers with percentages in parentheses unless otherwise indicated.

they would recommend the procedure to others. This compared with 91 percent of the OR and 100 percent of the RR patients. There were no differences for satisfaction ratings between the groups. Follow-Up of Randomized, Controlled Trial Patients Thirty-nine patients were randomized during the period 1995 to 1999; of those, six were dead, five were lost to follow-up, two refused to participate, and one was in a nursing home with severe dementia. The minimum followup was five (median, 7) years. From the RCT patients, there was one FTRP that required reoperation in the OR group (perineal proctosigmoidectomy) and one in the LR (Delormes procedure). Actuarial recurrence rates for LR and OR were 7 percent at five years (95 percent CI, 0–14) and the same at ten years because there were no additional events beyond five years. Long-term functional outcomes were available for 25 of the original 39 (62 percent). These results are summarized in Table 5. When functional outcomes were analyzed, there were no significant differences between the RCT group and the other patients treated off trial (data available from authors on request; Table 5).

DISCUSSION Previous studies conducted at RPAH suggest that LR is superior to OR in terms of short-term outcomes.4,7 There are economic advantages to LR over OR.5,10 However, relatively little is known regarding comparison of the long-term functional outcomes between OR and LR.6,11,12 This study is one of the largest long-term audits of functional outcomes after LR. The procedure has an acceptably low recurrence and does not have a deleterious effect on constipation as a group and has the anticipated improvement in anal continence. Patient satisfaction with LR was high, and rates of postoperative sexual or bladder dysfunction rates were low. Recurrence after surgery for FTRP is a key measure of successful outcome.1,12 The rate of recurrence does vary

with the type of repair, although to date the literature is reliant on case series for comparison because most randomized trials have short-term follow-up.5,6,11,13 Another problem with comparison of recurrence rates lies in the definition of recurrence. This study revealed that patients reported a fairly high recurrence rate (14.5 percent), which on further questioning and review most often was found to be anal mucosal prolapse. Recurrent anal mucosal prolapse is not necessarily a result of technical surgical deficiency but may be a source of patient dissatisfaction with surgery. For this study, we defined recurrence as being the rate of full-thickness recurrence requiring surgery (excluding banding) or documented by a surgeon (although there were no cases of FTRP that did not undergo further surgery). It can be argued that this definition of recurrence is restrictive and may underestimate recurrent prolapse. Other series have excluded patients who have undergone subsequent perineal procedures from their recurrence rates.14 The long-term operative recurrence rate of 4 percent in this study is comparable with other trials that look at longterm outcomes after OR.15–18 There were an additional seven patients who required operative procedures. The increase in recurrence compared with our prospective clinical trial (which was 0 percent recurrence at 24 months for LR) lends weight to the fact that recurrent FTRP is a phenomenon that increases as follow-up lengthens. Nevertheless, in this study the median period to further surgery for FTRP was only 12 (range, 3–40) months. Recent studies have reinforced the concept that actuarial recurrence rates should be standard when analyzing the outcomes of prolapse surgery and that actuarial rates vary by as much as 47 percent compared with crude recurrence.15,18 This study demonstrates such an increase with five-year and ten-year actuarial recurrence rates of 6.8 and 10.4 percent, respectively. Postoperative constipation has traditionally thought to have been the major postoperative problem with fixation rectopexy.1,12 This led to the development of RR, with the

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theory that removal of the redundant sigmoid colon could result in less kinking at the rectosigmoid angle and a subsequent improvement of transit into the rectum.12 Two randomized trials have attempted to address this issue with OR before the laparoscopic era.13,19 These two small trials, with a combined total of 48 participants, suggested a greater risk of postoperative constipation for patients who had rectopexy alone. The exact definition of postoperative constipation was vague in both studies, with the McKee et al. study13 looking at postoperative transit studies in the early postoperative phase and finding only an increase in transit time at Day 5 postoperatively. The Luukkonen et al. study involved greater numbers (n=30) and follow-up at six months revealed 5 of 15 patients in the rectopexy alone group were severely constipated, requiring repeat surgery.19 However, increased transit times were noted in both groups at six months, with no difference between the two groups with respect to transit time. A recent prospective, nonrandomized trial comparing two laparoscopic techniques in 34 patients revealed a 70 percent reduction in postoperative constipation in LR compared with a 64 percent reduction in constipation in laparoscopic-assisted resection rectopexy (LARR).20 The only theme that seems clear from these studies is that postoperative constipation after rectopexy is not well understood. Nevertheless, comparison between LR, OR, and RR in the current study failed to reveal significant long-term functional differences between the two groups. A recent publication from the Brisbane group of their ten-year experience in LARR revealed a long-term recurrence rate of full-thickness prolapse of 2.5 percent from 117 patients, although 18 percent required a Delorme procedure for recurrent mucosal prolapse.14 In comparison in the current RPAH series, the reoperation rate of 5 of 126 for FTRP (4 percent) is similar and the total reoperation rate of 12 of 126 (9.5 percent) for any problem is lower. This could be explained by a more aggressive approach to correcting anal mucosal prolapse in the Brisbane series. Sixty-nine percent of patients in the Brisbane cohort felt that their constipation improved postoperatively, and, in marked contrast to the present study and previous studies,20 no patient developed new constipation or worsened symptoms of constipation. In the current study, only 30 percent reported improved constipation and 30 percent felt worse. This data may be in keeping with the long held theory that constipation improves after RR. However, at RPAH approximately 30 percent of all groups had a deterioration in function or new onset constipation. Limitations of the current study included the low proportion of patients who were interviewed to assess functional outcomes. There was a higher than anticipated loss to follow-up, which may reflect the long median time to follow-up between five and seven years and the documented high mobility of the Australian population (40 percent of the population change address over 5 years).21 Furthermore, there were difficulties in establishing exactly what was

recurrence, hence the use of a strict, limited definition of recurrence. Many of the functional measures are subjective and may be subject to recall bias. The use of old instruments for measurement of constipation was a consequence of using the 1994 RCT as the basis for this study. Nevertheless, the data from this study indicate that good results can be achieved with LR in an institution with an expertise in laparoscopic colorectal surgery. Good outcomes can be achieved after LR and LARR, and these are superior to open techniques in the short-term. More data are required in the form of a large prospective, randomized trial that studies both short-term and long-term subjective and objective outcomes. To date, there has been no prospective, randomized trial comparing these two techniques, and the choice of surgery relies on results of case series published from mostly specialized single institutions. Australasian colorectal surgeons are currently recruiting patients on this multicenter, randomized, controlled trial funded in part by the Colorectal Surgical Society of Australia and New Zealand Research Foundation.

ACKNOWLEDGMENTS

The authors thank all of the patients who participated, and Christine Merlino and Pauline Byrne who interviewed the patients. REFERENCES 1. Senapti A. Rectal prolapse. In: Phillips RK. Colorectal surgery. Philadelphia: Saunders, 2001:251–71. 2. Azimuddin K, Khubchandani IT, Rosen L, Stasik JJ, Riether RD, Reed JF. Rectal prolapse: a search for the “best” operation. Am Surg 2001;67:622–7. 3. Kim DS, Tsang CB, Wong WD, Lowry AC, Goldberg SM, Madoff RD. Complete rectal prolapse: evolution of management and results. Dis Colon Rectum 1999;42:460–6. 4. Solomon MJ, Eyers AA. Laparoscopic rectopexy using mesh fixation with a spiked chromium staple. Dis Colon Rectum 1996;39:279–84. 5. Boccasanta P, Venturi M, Reitano MC, et al. Laparotomic vs. laparoscopic rectopexy in complete rectal prolapse. Dig Surg 1999;16:415–9. 6. 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;46:353–60. 7. Solomon MJ, Young CJ, Eyers AA, Roberts RA. Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse. Br J Surg 2002;89:35–9. 8. Luniss PJ, Kamm MA, Phillips RK. Factors affecting continence after surgery for anal fistula. Br J Surg 1994;81:1382–5. 9. Rome III Diagnostic Questionnaire for the Adult Functional GI Disorders (including Alarm questions) and Scoring Algorithm Appendix C. Available at http://www.

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