Laparoscopic Ventral Rectopexy for

Fecal Incontinence Associated with

High-grade Internal Rectal Prolapse
Oxford Pelvic Floor Centre
Department of Colorectal Surgery
Oxford, UK

Fecal incontinence

Debilitating

25% of institutionalized population

Factors

Sphincter

Neurological

CNS

Stool consistency

Drossman et al. US householder survey of functional gastrointestinal disorders:

prevalence, sociodemography and health impact. Dig Dis Sci. 1993;38:1569-1580

Rectal prolapse & Incontinence

Complex interaction

Anal resting pressure

Stretching of internal sphincter

Rectoanal inhibitory reflex (RAIR) disturbance

Incomplete emptying

Farouk, Duthie. Rectal prolapse and rectal invagination. Eur J Surg. 1998;164:323-332

Corrective procedures

Multiple over 50 years

High morbidity

Variable results

Laparoscopic ventral rectopexy? (LVR)

Asman HB. Internal procidentia of the rectum South Med J 1957;50:641-645

Methods

Aug 2009 July 2011

180 subjects with fecal incontinence

failed maximal medical treatment

74 LVR

Workup

Defecating proctogram

Anorectal physiology

Endoanal US

EUA

Oxford Prolapse Grade

Oxford Prolapse Grade

Questionnaires

Before & 1 year after surgery

Rockwood Fecal Incontinence Severity Index

Incontinence

Agachan-Wexner Constipation Score (1-5)

obstruction

FISI score decrease <50%= failure

Statistics

Mean, median with SD

Wilcoxon signed rank test

Comparing improvement

>50% FISI = success

Patient group comparison

Chi-square, Fisher exact test

Continuous variables Mann Whitney test

Pearson correlation- FISI:pre-op squeeze increment

Results

74 LVR

72 completed duration of study

52 (72%) proctogram

Remainder EUA

Complications in 9 patients (13%)

Urinary retention 7

Port site infection 1

Mesh erosion @5 mths - 1

Results @1 year

Median FISI score 31 15

EUA grp: 38 16

Proctogram grp: 30 12

Similar improvements

Oxford III and IV

Similar FISI scores

Results

21 patients completedly continent (29%)

53 patients FISI improved >25%

40 patients improved >50% (56%)

4 patients no change (6%)

8 patients worse off (11%)

Additional intervention

14 patients additional surgical procedure

12 patients sacral neuromodulation

2 patients repeat LVR for residual posterior

prolapse

Results Wexner score

Significantly reduced (median score)

13 vs 8 (p< 0.001)

6 patients (8%) minor deterioration

Mean increase 1.3

Results: Prediction of outcome

***Preop squeeze increment is an independent predictive factor of LVR

success

Discussion

Comparing Functional Outcome

FISI

Wexner

More than half showed procedural success

1/3 cured

Discussion

Fecal incontinent 27% has prolapse

Asymptomatic prolapse at menopause 23%

Why correction of prolapse in the symptomatic

population actually improves symptoms?

Lazorthes et al. Is rectal intussusception a cause of idiopathic incontinence? Dis

Colon Rectum. 1998;41:602-605
Goei & Baeten. Rectal intussusception and rectal prolapse: Detection and
postoperative evaluation with defecography. Radiology. 1990;174:124-126

Available data

Bristol group

91%

Int & external

Ihre & Seligson

77%

internal

Delemarre

62%

internal

Portier

98%

Orr-Loygue rectopexy

Samaranayake

45%

int & external

39/40

(systematic review of 12 case series, 728 patients)

Discussion

Improvement greater in patients with low

squeeze increment (<50mmHg)

External sphincter function

Urge incontinence : low anal squeeze pressures

If ext sphincter dysfunction, suppression of urge is

lost

?Internal prolapse abutting?

Engel et al. Relationship of symptoms in faecal incontinence in patients with rectal

prolapse Br J Surg 1994;81:743-746

Why LVR works?

Delemarre et al:

Anorectal physiology in 9 patients

Before & after rectopexy

Significant increase in maximal squeeze increment in

patients regained continence
Partial restoration of pelvic floor
More effective active and reflexive anal sphincter
action

Why LVR works

Abolition of high rectal pressure waves

Recovery of internal anal sphincter
electromyographic activity

Improvement in anorectal sensation

Increase in anal resting pressure

Limitation

Lack of anorectal manometry data

Post-rectopexy pelvic floor imaging

Comments

LVR has a role

Where does LVR stand in the treatment
algorithm?
Compared to sacral neurostimulation

Equal?

Better?

New questions to be answered

Patients with fecal incontinence associated with
high grade internal rectal prolapse

LVR

+/- Neurostimulation

***considering complications eg. mesh erosion

***general anaesthesia vs DC (neurostim.)

Thank you