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Harmston C.,Coventry University | Jones O.,Oxford Pelvic Floor Center
International Journal of Surgery | Year: 2011

External rectal prolapse is defined as a full thickness extrusion of the rectum outside of the anus. In patients who are fit enough, it is usually treated with surgical intervention. The surgical focus has traditionally been on reduction of the prolapse, rather than improvement in function. Internal rectal prolapse is also well recognised, being a folding of the full thickness of the rectal wall that occurs on straining to defecate, but that does not protrude outside of the anus. It may present with either obstructed defecation or faecal incontinence. 1,2 In contrast to external prolapse surgery for internal rectal prolapse has enjoyed a poor reputation, in part due to the poor results of surgery in the late 1980s. 3,4 but also because of the suggestion that internal prolapse is an incidental finding. 5 The introduction of surgical techniques that focus on functional outcomes in external prolapse surgery have led to a re-appraisal of the treatment of internal rectal prolapse. 6 This coupled with new evidence regarding the morphology of symptomatic internal prolapse has quashed the concept of internal prolapse as an untreatable and incidental phenomenon. 7,8This article will outline the evolution of surgery for rectal prolapse, the use of laparoscopic ventral rectopexy in external prolapse and the evaluation and treatment of patient with internal rectal prolapse. © 2011. Source

Gosselink M.P.,University of Oxford | Joshi H.,University of Oxford | Adusumilli S.,University of Oxford | van Onkelen R.S.,University of Oxford | And 6 more authors.
Journal of Gastrointestinal Surgery | Year: 2015

Aim: An external rectal prolapse (ERP) is often associated with faecal incontinence, and surgery is the recommended therapy. It has been suggested that correction of a high grade internal rectal prolapse (HIRP) is also worthwhile for patients with faecal incontinence. The aim of the present study is to compare the results of laparoscopic ventral rectopexy (LVR) in patients with faecal incontinence associated with either an ERP or a HIRP.Method: Consecutive patients suffering from faecal incontinence, who underwent a LVR between June 2010 and October 2012, were identified from a prospective database. All patients underwent preoperative defaecating proctography, anorectal manometry and ultrasound. Symptoms were assessed preoperatively and at 1 year after operation using a standardized questionnaire incorporating the Faecal Incontinence Severity Index (FISI; range 0–61) and the Gastrointestinal Quality of Life Index (GIQLI).Results: LVR was performed in 50 incontinent patients with a HIRP, and in 41 patients with an ERP. Preoperatively, the FISI was higher in patients with HIRP (HIRP 42 versus ERP 30, P < 0.01). The recurrence rate at 1 year was similar in both groups (HIRP 6 % versus ERP 2 %, P = 0.156). The FISI scores were significantly reduced in both groups (HIRP 48 % versus ERP 50 %, both P < 0.01). GIQLI was equally improved in both groups (HIRP 17 % versus ERP 18 %, both P < 0.01).Conclusion: Laparoscopic ventral rectopexy for the treatment of faecal incontinence achieves equivalent outcomes in both patients with an external rectal prolapse or high grade internal rectal prolapse. © 2014, The Society for Surgery of the Alimentary Tract. Source

Formijne Jonkers H.A.,Meander Medical Center | Draaisma W.A.,Meander Medical Center | Wexner S.D.,Cleveland Clinic | Broeders I.A.M.J.,Meander Medical Center | And 3 more authors.
Colorectal Disease | Year: 2013

Aim: Validated guidelines for the surgical and non-surgical treatment of rectal prolapse (RP) do not exist. The aim of this international questionnaire survey was to provide an overview of the evaluation, follow-up and treatment of patients with an internal or external RP. Method: A 36-question questionnaire in English about the evaluation, treatment and follow-up of patients with RP was distributed amongst surgeons attending the congresses of the European Association for Endoscopic Surgery and the European Society of Coloproctology in 2010. It was subsequently sent to all the members of the American Society of Colon and Rectal Surgeons and the European Society of Coloproctology by e-mail. Results: In all, 391 surgeons in 50 different countries completed the questionnaire. Evaluation, surgical treatment and follow-up of patients with RP differed considerably. For healthy patients with an external RP, laparoscopic ventral rectopexy was the most popular treatment in Europe, whereas laparoscopic resection rectopexy was favoured in North America. There was consensus only on frail and/or elderly patients with an external prolapse, with a preference for a perineal technique. After failure of conservative therapy, internal RP was mostly treated by laparoscopic resection rectopexy in North America. In Europe, laparoscopic ventral rectopexy and stapled transanal rectal resection were the most popular techniques for these patients. Conclusion: The treatment of RP differs between surgeons, countries and regions. Guidelines are lacking. Prospective comparative studies are warranted that may result in universally accepted protocols. © 2012 The Authors Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland. Source

Harmston C.,Oxford Pelvic Floor Center | Jones O.M.,Oxford Pelvic Floor Center | Cunningham C.,Oxford Pelvic Floor Center | Lindsey I.,Oxford Pelvic Floor Center
Colorectal Disease | Year: 2011

Aim Faecal incontinence is commonly seen in patients with internal rectal prolapse (IRP), although the mechanism is not clear. This study assessed the relationship between IRP and anal sphincter function. Method Patients both with IRP diagnosed on proctography and those with external rectal prolapse (ERP) were identified from a prospective database generated from a tertiary referral pelvic floor clinic. The results of anorectal manometry were analysed, and the relationship between sphincter pressure and grade of prolapse was assessed. Results A total of 515 patients were identified with clinical evidence of ERP or proctographic evidence of internal and external prolapse. There were 88 with grade 5 or external prolapse [mean maximal resting pressure (MRP) 28.5 (standard error 2.1) mmHg], 156 with grade 4 prolapse [44.0 (1.8) mmHg], 153 with grade 3 prolapse [49.2 (1.6) mmHg], 88 with grade 2 prolapse [56.2 (2.1) mmHg] and 29 patients with grade 1 rectal prolapse [56.8 (4.5) mmHg]. There was a significant reduction in the mean MRP with increasing grade of prolapse from grade 2 to 5. By contrast, there was no relationship between prolapse grade and mean maximal squeeze pressure, except in patients with ERP, in whom the squeeze pressure was significantly lower compared with patients with IRP. Conclusion This is the first large-scale study to show the relationship between internal prolapse and MRP. The observation that squeeze pressure is unchanged suggests that the effect of internal prolapse on continence occurs mainly through a reduction in internal anal sphincter tone. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland. Source

Ragg J.,Oxford Pelvic Floor Center | McDonald R.,Oxford Pelvic Floor Center | Hompes R.,Oxford Pelvic Floor Center | Jones O.M.,Oxford Pelvic Floor Center | And 2 more authors.
Colorectal Disease | Year: 2011

Aim Chronic constipation is classified as outlet obstruction, colonic inertia or both. We aimed to determine the incidence of isolated colonic inertia in chronic constipation and to study symptom pattern in those with prolonged colonic transit time. Methods Chronic constipation patients were classified radiologically by surgeon-reported defaecating proctography and transit study into four groups: isolated outlet obstruction, isolated colonic inertia, outlet obstruction plus colonic inertia, or normal. Symptom patterns were defined as stool infrequency (twice weekly or less) or frequent unsuccessful evacuations (more than twice weekly). Results Of 541 patients with chronic constipation, 289 (53%) were classified as isolated outlet obstruction, 26 (5%) as isolated colonic inertia, 159 (29%) as outlet obstruction plus colonic inertia and 67 (12%) as normal. Of 448 patients (83%) with outlet obstruction, 35% had additional colonic inertia. Only 14% of those with prolonged colonic transit time had isolated colonic inertia. Frequent unsuccessful evacuations rather than stool infrequency was the commonest symptom pattern in all three disease groups (isolated outlet obstruction 86%, isolated colonic inertia 54% and outlet obstruction plus colonic inertia 63%). Conclusion Isolated colonic inertia is an unusual cause of chronic constipation. Most patients with colonic inertia have associated outlet obstruction. These data question the clinical significance of isolated colonic inertia. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland. Source

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