What does the future hold for ventral rectopexy?

摘要

Although multiple operations have been described for the surgical treatment of rectal prolapse over the past 150 years, there have been very few trials conducted to compare treatments and even fewer to compare the functional outcomes. One of the largest randomised trials conducted in the field of pelvic floor surgery is the well-known PROSPER trial comparing abdominal with perineal approaches. [[1]Senapati A. Gray R.G. Middleton L.J. Harding J. Hills R.K. Armitage N.C. Buckley L. Northover J.M. PROSPER Collaborative GroupPROSPER: a randomised comparison of surgical treatments for rectal prolapse.Colorectal Dis. 2013; 15: 858-868Crossref PubMed Scopus (157) Google Scholar] Although there was a clear trend in favour of resection rectopexy with a recurrence rate of 13% (suture rectopexy 26%, perineal rectosigmoidectomy 24%, Delorme's 31%) there was no significant differences declared in the randomised comparisons although substantial improvements in the quality of life were noted following all procedures. However, only 293 of the original target 950 patients were recruited when the trial was stopped. As such it is not appropriate to consider this to be evidence of equivalence between abdominal and perineal approaches for treatment of rectal prolapse. Ventral rectopexy was not included as one of the choices in the PROSPER trial as it had not been widely performed at the time that the trial was commenced, even though it had been performed by small groups in Europe since the 1950′s/1960′s. Indeed, the term “ventral rectopexy” was first used in a paper by the German Surgeon F. Deuscher in 1960. [[2]Deucher F. Ventral rectopexy in the treatment of rectal prolapse].Helv Chir Acta. 1960; 27: 240-246PubMed Google Scholar] A number of centres in Europe and the United Kingdom started performing the modern interpretation of the ventral rectopexy using minimally invasive approaches. [[3]D'Hoore A. Cadoni R. Penninckx F Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse.Br J Surg. 2004; 91: 1500-1505Crossref PubMed Scopus (352) Google Scholar] The principle advantage of the ventral approach is the avoidance of the posterior mobilisation and preservation of rectal function with avoidance of postoperative constipation. In a follow up to the PROSPER trial, which examined the surgical practices for external rectal prolapse in 1997 with 2014, there was a clear change towards abdominal approach. [[4]Life after PROSPERWhat do people do for external rectal prolapse?.Gunner CK, Senapati A, Northover JM, Brown SR. Colorectal Dis. 2016; 18: 811-814PubMed Google Scholar] There had also been a dramatic increase in the preference for ventral rectopexy with matching decrease in the number of both posterior rectopexy and resection rectopexy during that time. However, with the recent concerns with mesh complications, some centres have become reluctant to perform ventral rectopexy. Although excellent longterm data with regard to the safety, functional outcomes and recurrence after ventral rectopexy have been reported [[5]Evans C. Stevenson A.R.L. Sileri P. Mercer-Jones M.A. Dixon A.R. Cunningham C. et al.A multicenter collaboration to assess the safety of laparoscopic ventral rectopexy.Dis Colon Rectum. 2015; 58: 799-807Crossref PubMed Scopus (88) Google Scholar,[6]Consten E.C.J. Van Iersel J.J. Verheijen P.M. Broeders I.A.M.J. Wolthuis A.M. D'Hoore A Long-term outcome after laparoscopic ventral mesh rectopexy.Ann Surg. 2015; 262: 742-748Crossref PubMed Scopus (127) Google Scholar], to date there has only been one randomised trial comparing the preoperative to postoperative functional outcomes for ventral rectopexy (VR) versus posterior suture rectopexy (PSR). This trial was based on a relatively small group of 72 patients from a single centre in Denmark and reported in 2016. [[7]Lundby L. Iversen L.H. Buntzen S. Wara P. Høyer K. Laurberg S Bowel function after laparoscopic posterior sutured rectopexy versus ventral mesh rectopexy fo