EXPRESSION OF CONCERN: Consensus on ventral rectopexy: report of a panel of experts

摘要

Ventral rectopexy (VR) has gained in popularity amongst colorectal surgeons as an operation that addresses functional bowel symptoms by correcting anatomical abnormalities in patients with internal (rectal intussusception) and external rectal prolapse. The operation includes fixation of a synthetic or biological implant to the ventral rectum and vaginal vault. There is current concern over the fixation of any material placed transvaginally or paravaginally in pelvic organ prolapse surgery because of the risks of erosion and sepsis 1. Concerns have also been expressed regarding patient selection for VR, choice of material, operative technique and a lack of high-level evidence. In order to address these concerns, two Consensus Conferences were held, the first on 25 September 2012 at the Austria Trend Hotel, Vienna, Austria and the second on 17 May 2013 at St John's College, Oxford, UK to develop a consensus opinion from expert colorectal surgeons with a subspeciality of pelvic floor practice and experience of performing VR. Most had performed 100 or more ventral rectopexies. The goal of pelvic organ prolapse surgery is to restore anatomy and improve function and quality of life. Despite its shortcomings, the PROSPER trial conducted by the Association of Coloproctology of Great Britain and Ireland (ACPGBI), which compared surgical treatments for external rectal prolapse, showed high recurrence rates for perineal and posterior abdominal rectal approaches 2, but it did show improved quality of life. VR emerged as a new, autonomic nerve-sparing operation for external rectal prolapse 3. Anterior mobilization had been described in the early 1980s 4, but VR was new because it avoided a posterior rectal mobilization. Posterior mobilization was shown in randomized studies 5, 6 to be associated with rectal inertia, and a Cochrane Review of external prolapse concluded that it was associated with more postoperative constipation 7. A systematic review comparing ventral and posterior rectal mobilization also concluded that the former was associated with less constipation 8. Unlike posterior rectopexy, VR had the potential to correct any coexisting middle compartment prolapse. Five-year recurrence rates of less than 5% and improvements in faecal incontinence are acceptable 3, and similar to those established for posterior rectopexy 9. Laparoscopic surgery has made the application of these techniques safer than with open surgery. Laparoscopic posterior rectopexy was established well before laparoscopic VR, but because the dissection was no different from posterior rectopexy, the functional problems remained 8. It was the improvement in constipation in most patients following VR which attracted the attention of surgeons 3. In the 1980s and 1990s, poor function after posterior rectopexy 10 and a belief that internal rectal prolapse was a variant of normal 11 seldom leading to external rectal prolapse 12 resulted in a 'medicalization' of treatment and a reduction of surgery. With a better understanding of internal rectal prolapse as a morphologically distinct finding in patients with evacuation disorder 13 combined with improved defaecation after VR for external prolapse, led to its adoption for internal rectal prolapse 14. Medium-term results were reported for patients with mechanical outlet obstruction and external or internal rectal prolapse 15. At a median follow-up of 54 months, there was no recurrence of external prolapse and a more than 80% improvement in constipation and incontinence scores. Collinson et al. 16 and others 17, 18 reported similar excellent short-term functional results for patients with internal rectal prolapse. Recent publications have shown improvements in quality of life and sexual function after VR 17, 19, 20, although an earlier study had reported little improvement following VR for symptomatic rectocele 21. All series demonstrated VR to be safe with no mortality and an acceptably minimal morbidity. Despite the increas