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Background Traditionally, perforated diverticulitis has been managed with an open approach, with a Hartmann procedure or a colectomy with primary anastomosis. Minimally invasive surgery is associated with postoperative advantages in the elective setting and may show a benefit in the emergent setting. Objective The aim of this study was to compare postoperative outcomes of open vs minimally invasive approaches for emergent perforated diverticulitis. Design This was a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database using propensity score matching. Settings Interventions were performed in hospitals participating in the national database. Patients Patients who underwent emergent colectomy from 2012 to 2017 were included. Procedures were divided into Hartmann procedure and primary anastomosis. Open vs minimally invasive groups were defined by intention to treat. Main outcome measures Outcomes measures included length of stay and overall morbidity and mortality. Results Of 130,616 patients, 7105 met inclusion criteria (4486 Hartmann procedure and 2619 primary anastomosis). A total of 1989 open Hartmann procedure cases were matched to 663 minimally invasive cases. The minimally invasive group underwent longer operations and had lower rates of respiratory failure. There were no differences in overall complications, mortality, length of stay, or home discharge. In the primary anastomosis group, 1027 cases were matched 1:1. The minimally invasive approach was associated with longer operative times, but reduced wound dehiscence, sepsis, bleeding, overall complications, and length of stay. No difference was detected in anastomotic leak, mortality, reoperation, or readmission rates. Limitations Limitations include retrospective nature, data loss, nonuniformity, selection bias, and coding errors. Conclusions Emergent minimally invasive primary anastomosis results in a shorter length of stay and decreased 30-day morbidity in comparison with open primary anastomosis for perforated diverticulitis. Emergent open and minimally invasive Hartmann procedures for perforated diverticulitis have comparable outcomes, perhaps because of a 40% conversion rate. See Video Abstract at http://links.lww.com/DCR/B421. Abordaje abierto versus mnimamente invasivo para colectoma de emergencia en diverticulitis perforada ANTECEDENTES:Tradicionalmente, la diverticulitis perforada se ha tratado con un abordaje abierto, con un procedimiento de Hartmann o una colectomia con anastomosis primaria. La cirugia minimamente invasiva se asocia con ventajas posoperatorias en el escenario electivo y puede mostrar beneficio en el escenario emergente.OBJETIVO:El objetivo de este estudio fue comparar los resultados posoperatorios del abordaje abierto versus el minimamente invasivo para la diverticulitis perforada emergente.DISENO:Esta fue una revision retrospectiva de la base de datos de colectomia dirigida del Programa Nacional de Mejoramiento de la Calidad Quirurgica del Colegio Americano de Cirujanos utilizando el pareamiento por puntaje de propension.ESCENARIO:Las intervenciones se realizaron en los hospitales participantes en la base de datos nacional.PACIENTES:Se incluyeron pacientes que fueron sometidos a colectomia emergente de 2012 a 2017. Los procedimientos se dividieron en procedimiento de Hartmann y anastomosis primaria. Los grupos abierto versus minimamente invasivo se definieron por intencion de tratar.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado incluyeron la duracion de la estancia, la morbilidad general y la mortalidad.RESULTADOS:De 130,616 pacientes, 7,105 cumplieron los criterios de inclusion (4,486 procedimiento de Hartmann y 2,619 anastomosis primaria). 1,989 casos abiertos de procedimientos de Hartmann se emparejaron con 663 casos minimamente invasivos. El grupo minimamente invasivo se sometio a operaciones mas prolongadas y tuvo tasas mas bajas de insuficiencia respiratoria. No hubo diferencias en las complicaciones generales, la mortalidad, la duracion de la estancia o el alta domiciliaria. En el grupo de anastomosis primaria, 1,027 casos se emparejaron 1: 1. El abordaje minimamente invasivo se asocio con tiempos quirurgicos mas prolongados, pero tambien con tasas reducidas de dehiscencia de herida, sepsis, sangrado, complicaciones generales y la duracion de la estancia. No se detectaron diferencias en las tasas de fuga anastomotica, mortalidad, reintervencion o reingreso.LIMITACIONES:Las limitaciones incluyen la naturaleza retrospectiva, perdida de datos, falta de uniformidad, sesgo de seleccion y errores de codificacion.CONCLUSIONES:La anastomosis primaria minimamente invasiva emergente resulta en una estancia mas corta y una disminucion de la morbilidad a los 30 dias en comparacion con la anastomosis primaria abierta para la diverticulitis perforada. El procedimiento de Hartmann abierto y minimamente invasivo de emergencia para la diverticulitis perforada tiene resultados comparables, quizas debido a una tasa de conversion del 40%. Consulte el Video Resumen en http://links.lww.com/DCR/B421.

Diverticular disease is a common problem where patients with diverticulosis have a 1–4 per cent risk of acute diverticulitis. Current guidelines recommend a colonoscopy after.the resolution of acute diverticulitis. The aim of this study was to evaluate the yield of significant findings on colonoscopy after an episode of diverticulitis. This is a retrospective analysis of patients who underwent colonoscopy after an episode of diverticulitis between November 2005 and August 2017 at three major teaching hospitals. Advanced adenomas were defined as adenomas ≥1 cm, serrated adenomas, and tubulovillous or villous adenomas. A total of 584 patients (298 males; 51%) underwent colonoscopy for a history of diverticulitis after resolution of acute symptoms. Colonoscopy was complete in 488 patients (84%). Among these 488 patients, 446 had diverticular disease, 31 had advanced adenomas, and four had adenocarcinomas. Colonoscopies were incomplete in 96 patients (16%). Forty-six of those patients underwent surgery. The overall incidence of advanced adenomas and adenocarcinomas was 32 (5.4%) and nine (1.5%), respectively. In our study, the prevalence of advanced adenomas and adenocarcinomas was relatively high compared with the average risk individuals. Our findings support that patients after an episode of diverticulitis should continue to get a colonoscopy.

Background Chronic anal fissure (CAF) is commonly treated by colorectal surgeons. Pharmacological treatment is considered first-line therapy. An alternative treatment modality is chemical sphincterotomy with injection of botulinum toxin (BT). However, there is a lack of a consensus on the BT administration procedure among colorectal surgeons. Methods A national survey approved by the American Society of Colon and Rectal Surgeons (ASCRS) Executive Council was sent to all members. An eight-question survey was sent via ASCRS email correspondence between December 2019 and February 2020. Questions were derived from available meta-analyses and expert opinions on BT use in CAF patients and included topics such as BT dose, injection technique, and concomitant therapies. The survey was voluntary and anonymous, and all ASCRS members were eligible to complete it. Responses were recorded and analyzed via an online survey platform. Results 216 ASCRS members responded to the survey and 90% inject 50-100U of BT. Most procedures are performed under MAC anesthesia (56%). A majority of respondents (64%) inject into the internal sphincter and a majority (53%) inject into 4 quadrants in the anal canal circumference. Some respondents perform concomitant manual dilatation (34%) or fissurectomy (38%). Concomitant topical muscle relaxing agents are not used uniformly among respondents. Discussion Injection of BT for CAF is used commonly by colorectal surgeons. There is consensus on BT dosage, administration site, technique, and the use of monitored anesthesia care.

BACKGROUND Hemorrhoids are common and affect mainly the young and middle-aged populations. Current guidelines recommend treating grade I and II hemorrhoids with office-based procedures. These therapies usually require multiple applications. Hemorrhoid energy therapy treats the hemorrhoids at 1 treatment session. OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of hemorrhoid energy therapy. DESIGN This was a prospective pilot study evaluating patients with symptomatic grade I and II internal hemorrhoids. SETTINGS The study was conducted at a tertiary academic center. PATIENTS Patients over the age of 18 years with chronic, symptomatic grade I and II internal hemorrhoids who failed 2 weeks of conservative therapy were enrolled between July 2015 and January 2019. Exclusion criteria included patients with grade III or IV internal hemorrhoids, external hemorrhoids, nonhemorrhoidal GI bleeding, active proctitis, and IBD. INTERVENTIONS Hemorrhoid energy therapy was administered in clinic, and 2 postprocedure visits were completed. A pretreatment hemorrhoid symptom score was obtained from each patient. A visual analog score was assessed posttreatment. MAIN OUTCOME MEASURES The primary end point was to evaluate the effect of hemorrhoid energy therapy on hemorrhoid symptoms and its safety. The secondary end point was evaluation of postprocedural pain. RESULTS A total of 35 patients were enrolled. The mean duration of hemorrhoid symptoms was 3.3 ± 6.4 years, and rectal bleeding and hemorrhoidal prolapse were the most common symptoms. After the procedure, patient hemorrhoid symptom scores decreased from mean 5.5 to 1.4. The mean immediate postprocedural visual analog score was 2.4 ± 2.1 and decreased to

Anorectal continence is determined by numerous factors, including the function of internal and external anal sphincters, anal sensation, anorectal angle, stool consistency, and rectal compliance. Disturbances in one or several of these factors may cause fecal incontinence; hence treatment options vary based on the etiology and severity. Common causes include obstetric trauma, prior anorectal surgery, and altered bowel habits. Prior to initiating treatment, candidates for anal sphincter repair should obtain a full diagnostic workup. If a distinct defect is identified, sphincter repair is one treatment option and is usually performed with an overlapping technique. Overlapping sphincteroplasty remains a viable surgical treatment option for isolated, preferably anterior, sphincter defects.

The incidence of pelvic floor disorders has been rapidly increasing in the last decades. Surgical management and repair techniques have evolved with the introduction of laparoscopic ventral mesh rectopexy (LVMR), which has become the favored treatment for rectal prolapse for many of surgeons around the world.

Obstructed defecation syndrome (ODS) is a broad term, and it is usually associated with “difficulty in evacuation”, but frequently also with defecatory dysfunction and/or constipation. These disorders are frequently encountered in clinical practice and it is estimated to affect about 20% of the population. ODS is frequently associated with one or several conditions, including pelvic dyssynergia (nonrelaxing puborectalis), rectocele, rectal procidentia (internal or external rectal prolapse), enterocele, and pelvic organ prolapse. Various conservative treatments have been applied to improve the physiology of ODS, but sometimes surgical intervention can be needed to improve patients’ symptoms. Surgical treatment of ODS however remains challenging. Different surgical approaches exist to treat patients with ODS, however, all techniques have their advantages and disadvantages. Therefore each surgery should be individualized to the particular patient with a focus on multidisciplinary approach.

Background Current guidelines suggest that transplant patients with acute diverticulitis should be managed aggressively with early operative intervention to reduce morbidity and mortality. This study compared the treatment choices and clinical outcomes between renal transplant patients and immunocompetent patients with acute diverticulitis. Methods A retrospective review was performed of all patients who were admitted with acute diverticulitis between 2002 and 2015 at a single academic institution. Patient demographics, comorbidities, physiologic and radiologic disease severity, management, and disease-specific outcomes were recorded and compared between renal transplant patients and immunocompetent patients. Predictors of complications also were analyzed. Results In the study, 20 renal transplant patients and 134 immunocompetent patients were admitted for acute diverticulitis and were followed for a median time of 36 and 40 months, respectively. Patient demographics were similar between the groups. Transplant patients had significantly more comorbidities. Overall, there were no differences in physiologic disease severity or rates of elective or urgent operation, ostomy, permanent ostomy, duration of stay, 30-day readmission, disease recurrence or disease-specific complications, organ failure, or death. Among patients with complicated disease, renal transplant patients were significantly more likely to undergo an urgent operation and had more complications. On multivariate analysis, undergoing operative therapy remained the sole predictor of complications. Conclusion Nonoperative management of renal transplant patients who present with uncomplicated diverticulitis is safe as outcomes are similar to immunocompetent patients. However, the optimal management of renal transplant patients with complicated diverticulitis remains unclear as both treatment choices and complication rates differed from immunocompetent patients.

Sphincter-sparing repairs are commonly used to treat anal fistulas with significant muscle involvement.The current study evaluates the trends and efficacy of sphincter-sparing repairs and determines risk factors for fistula recurrence.A retrospective review was performed at 3 university-affiliated teaching hospitals.All 462 patients with cryptoglandular anal fistulas who underwent 573 sphincter-sparing repairs between 2005 and 2015 were included. Patients with Crohn's disease were excluded.The primary outcome was the rate of fistula healing defined as cessation of drainage with closure of the external opening. Risk factors for nonhealing were also analyzed.Five hundred three sphincter-sparing repairs were analyzed, whereas 70 were lost to follow-up. Two hundred twenty sphincter-sparing repairs (44%) resulted in healing, 283 (56%) resulted in nonhealing with a median follow-up of 9 (range, 1-125) months. The median time to fistula recurrence was 3 (range, 0-75) months with 79% and 91% of recurrences noted within 6 and 12 months. Patients treated with a dermal advancement flap, rectal advancement flap, or ligation of the intersphincteric tract procedure were less likely to have a recurrence than patients treated with a fistula plug or fibrin glue (p0.001). Over time, there was a significantly increased use of the ligation of the intersphincteric tract procedure (p0.001) and a significantly decreased use of fistula plugs and fibrin glue (p0.001); healing rates improved accordingly. There were no significant differences in healing rates with respect to patient demographics, comorbidities, or fistula characteristics.This study was limited by its retrospective design.Healing rates following sphincter-sparing repairs of cryptoglandular anal fistulas are modest, but have improved over time with the use of better surgical techniques. In this study, ligation of the intersphincteric fistula tract and flaps were superior to fistula plugs and fibrin glue; the former procedures are therefore favored. See Video Abstract at http://links.lww.com/DCR/A391.

Aim Sacral nerve stimulation has become a preferred method for the treatment of faecal incontinence in patients who fail conservative (non-operative) therapy. In previous small studies, sacral nerve stimulation has demonstrated improvement of faecal incontinence and quality of life in a majority of patients with low anterior resection syndrome. We evaluated the efficacy of sacral nerve stimulation in the treatment of low anterior resection syndrome, using a recently developed and validated low anterior resection syndrome instrument to quantify symptoms. Method A retrospective review of consecutive patients undergoing sacral nerve stimulation for the treatment of low anterior resection syndrome was performed. Procedures took place in the Division of Colon and Rectal Surgery at two academic tertiary medical centers. Pre and post treatment Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome Scores were assessed. Results Twelve patients (50% men) suffering from low anterior resection syndrome with a mean age of 67.8 (±10.8) years underwent sacral nerve test stimulation. Ten patients (83%) proceeded to permanent implantation. Median time from anterior resection to stimulator implant was 16 (range, 5-108) months. At a median follow-up of 19.5 (range, 4-42) months, there were significant improvements in Cleveland Clinic Incontinence Scores and the Low Anterior Resection Syndrome Scores (p

Background The aim of this study was to evaluate the clinical utility and cost-effectiveness of routine histologic examination of the doughnuts from stapled anastomoses in patients undergoing a low anterior resection for rectal cancer. Methods We performed a retrospective review of 486 patients who underwent a low anterior resection with stapled anastomosis for rectal cancer between 2002 and 2015 at 3 institutions. Pathologic findings in the doughnuts and their impact on patient management were recorded. Tumor characteristics that may influence how often doughnuts were included in the pathology report were analyzed. An approximate cost of histologic examination of doughnuts was also calculated. Results A total of 412 patients (85%) had doughnuts included in their pathology reports. Two patients had cancer cells in their doughnuts, and both patients had a positive distal margin in their primary tumor specimen; 33 patients had benign findings in their doughnuts. Pathologic examination of the doughnut did not change clinical management in any patient. Patients with rectosigmoid tumors were less likely to have their doughnuts included in the pathology report compared to patients with low tumors ( P = .003). Doughnuts were not bundled with the primary tumor specimen in 374 (77%) of our patients; in these patients, pathologic analysis of the doughnut added an additional cost of approximately $643 per specimen. Conclusion This study demonstrates no clinical benefit in sending anastomotic doughnuts for histopathologic evaluation after performing a low anterior resection with a stapled anastomosis for rectal cancer. Overall cost may be decreased if doughnuts are not analyzed or if they are bundled with the primary tumor specimen.

Anal fistulas continue to be a problem for patients and surgeons alike despite scientific advances. While patient and anatomical characteristics are important to surgeons who are evaluating patients with anal fistulas, their development and persistence likely involves a multifaceted interaction of histological, microbiological, and molecular factors. Histological studies have shown that anal fistulas are variably epithelialized and are surrounded by dense collagen tissue with pockets of inflammatory cells. Yet, it remains unknown if or how histological differences impact fistula healing. The presence of a perianal abscess that contains gut flora commonly leads to the development of anal fistula. This implies a microbiological component, but bacteria are infrequently found in chronic fistulas. Recent work has shown an increased expression of proinflammatory cytokines and epithelial to mesenchymal cell transition in both cryptoglandular and Crohn's perianal fistulas. This suggests that molecular mechanisms may also play a role in both fistula development and persistence. The aim of this study was to examine the histological, microbiological, molecular, and host factors that contribute to the development and persistence of anal fistulas.

AIM Frailty is defined as a decrease in physiological reserve with increased risk of morbidity following significant physiological stressors. This study examines the predictive power of the five-item modified frailty index (5-mFI) in predicting outcomes in colorectal surgery patients. METHODS The American College of Surgeons National Surgical Quality Improvement Program Database was queried from 2011 to 2016 to determine the predictive power of 5-mFI in patients who had colorectal surgery. RESULTS Of 295 490 patients, 45.8% had a score of 0, 36.2% had a score of 1 and 18% had a score of ≥ 2. On univariate analysis, frailer patients had significantly greater incidences for overall morbidity, serious morbidity, mortality, prolonged length of hospital stay, discharge to a facility other than home, reoperation and unplanned readmission. These findings were consistent on multivariate analysis where the frailest patients had greater odds of postoperative overall morbidity (OR 1.39; 95% CI 1.35-1.43), serious morbidity (OR 1.39; 95% CI 1.33-1.45), mortality (OR 2.00; 95% CI 1.87-2.14), prolonged length of hospital stay (OR 1.24; 95% CI 1.20-1.27), discharge destination to a facility other than home (OR 2.80; 95% CI 2.70-2.90), reoperation (OR 1.17; 95% CI 1.11-1.23) and unplanned readmission (OR 1.31; 95% CI 1.26-1.36). Weighted kappa statistics showed strong agreement between the 5-mFI and 11-mFI (kappa = 0.987, P

BACKGROUND The rates of recurrent prolapse after perineal proctectomy vary widely in the literature, with incidences ranging between 0% and 50%. The Thiersch procedure, first described in 1891 for the treatment of rectal prolapse, involves encircling the anus with a foreign material with the goal of confining the prolapsing rectum above the anus. The Bio-Thiersch procedure uses biological mesh for anal encirclement and can be used as an adjunct to perineal proctectomy for rectal prolapse to reduce recurrence. OBJECTIVE The aim of this study was to evaluate the Bio-Thiersch procedure as an adjunct to perineal proctectomy and its impact on recurrence compared with perineal proctectomy alone. DESIGN A retrospective review of consecutive patients undergoing perineal proctectomy with and without Bio-Thiersch was performed. SETTINGS Procedures took place in the Division of Colon and Rectal Surgery at a tertiary academic teaching hospital. PATIENTS Patients who had undergone perineal proctectomy and those who received perineal proctectomy with Bio-Thiersch were evaluated and compared. INTERVENTIONS All of the patients with rectal prolapse received perineal proctectomy with levatorplasty, and a proportion of those patients had a Bio-Thiersch placed as an adjunct. MAIN OUTCOME MEASURES The incidence of recurrent rectal prolapse after perineal proctectomy alone or perineal proctectomy with Bio-Thiersch was documented. RESULTS Sixty-two patients underwent perineal proctectomy (8 had a previous prolapse procedure), and 25 patients underwent perineal proctectomy with Bio-Thiersch (12 had a previous prolapse procedure). Patients who received perineal proctectomy with Bio-Thiersch had a lower rate of recurrent rectal prolapse (p < 0.05) despite a higher proportion of them having had a previous prolapse procedure (p < 0.01). Perineal proctectomy with Bio-Thiersch had a lower recurrence over time versus perineal proctectomy alone (p < 0.05). LIMITATIONS This study was limited by nature of being a retrospective review. CONCLUSIONS Bio-Thiersch as an adjunct to perineal proctectomy may reduce the risk for recurrent rectal prolapse and can be particularly effective in patients with a history of previous failed prolapse procedures.

Rectal prolapse can be repaired through an abdominal or perineal approach. Choosing between these approaches has traditionally focused on patient age and comorbidities; younger, healthier patients undergo an abdominal procedure while elderly patients often receive a perineal procedure [1, 2]. In North America, abdominal repair is frequently carried out with laparoscopic posterior rectopexy, with or without resection, while perineal repair is performed with an Altemeier procedure. Meanwhile, in Europe, and laparoscopic ventral rectopexy takes precedence as the preferred abdominal repair and the Delorme procedure is utilized more frequently [2].

Fistula between an ileal pouch and the vagina, anus, or perineum is an uncommon complication of ileal pouch-anal anastomosis and is a cause of considerable morbidity. Its optimal management has not been determined because of its low incidence. The aim of this study was to review the outcomes of patients who presented with symptomatic ileal pouch-associated fistulas after restorative proctocolectomy (RPC) and to present a diagnostic and treatment algorithm.Retrospective review of patients treated for symptomatic ileal pouch-associated fistulas after RPC from 1989 to 2011.Twenty-five patients (14 men, mean age 40 years) were presented with symptomatic ileal pouch-associated fistulas. Median time to pouch fistula following RPC was 6.9 years (range 1 month-20 years). Fistulas were classified as pouch-anal (n = 12, 48 %), pouch-vaginal (n = 7, 28 %), complex (n = 4, 16 %), and pouch-perineal (n = 2, 8 %). Etiology included Crohn's disease (n = 15, 60 %), cryptoglandular (n = 6, 24 %), and anastomotic failure (n = 4, 16 %). Each patient underwent an average of 2.8 local procedures or repairs. Overall healing rate was 64 % at a median follow-up of 29 (range 2-108) months. None of the complex fistulas were healed. Postoperative pelvic sepsis, fecal diversion, anti-tumor necrosis factor therapy, and fistula etiology did not significantly impact fistula healing. Three patients required pouch excision with end ileostomy.Operative treatment of pouch fistulas after RPC resulted in complete healing in 64 % of patients following a stepwise diagnostic and therapeutic approach.

OBJECTIVES The TOPAS AMS pelvic floor repair system is a self-fixating polypropylene mesh intended for use to reinforce soft tissues where weakness exists in the gynecological and gastroenterological anatomy. It is not available commercially in any country. This was a preliminary study conducted to obtain initial clinical experience with the TOPAS system for the treatment of fecal incontinence (FI) in women. METHODS This was a prospective study conducted at 5 centers in the United States. Women with FI who failed 1 or more conservative therapies were candidates for the study. Fecal incontinence was assessed with a bowel diary, Cleveland Clinic incontinence scores (CCISs), and Fecal Incontinence Quality of Life (FIQOL) questionnaires, and patients were followed prospectively up to 24 months. Treatment success was defined as a reduction in number of FI episodes of 50% or more compared with baseline. RESULTS A total of 29 women (mean age, 60.6 years) were implanted with the TOPAS system. Mean number of FI episodes per 14 days decreased from 6.9 at baseline to 3.5 at 24 months of follow-up, and the reduction was significant for the entire follow-up period compared with baseline (P < 0.001). A total of 55.6% of the subjects reported treatment success. The CCIS and FIQOL scores for all domains were significantly improved during the overall follow-up period compared with baseline (P < 0.001). The most common procedure and/or device-related adverse events were de novo urinary incontinence, including bladder spasms (n = 6), worsening FI (n = 2), and constipation (n = 2). No device-related erosions or extrusions were reported. CONCLUSIONS Initial experience of the TOPAS system demonstrated a significant improvement in FI episodes, CCIS and FIQOL scores, and a benign safety profile. These results indicate that the TOPAS system has potential as a new therapeutic option for FI, but it needs to be confirmed in a larger study.

Transanal endoscopic microsurgery has gained increasing popularity as a treatment alternative for early stage rectal neoplasms. With continued advances in technique and experience, more proximal rectal tumors are being surgically managed by using transanal endoscopic microsurgery with an intraperitoneal anastomosis.The purpose of this study was to review the outcomes of patients who have undergone intraperitoneal anastomosis with the use of the transanal endoscopic microsurgery technique.A prospective, single-surgeon database documented 445 consecutive patients undergoing transanal endoscopic microsurgery from October 1, 1996 through January 1, 2012. We retrospectively reviewed information from all patients who underwent transanal endoscopic microsurgery with an intraperitoneal anastomosis in this prospective database.All procedures took place in an inpatient hospital setting.All patients satisfied workup criteria to undergo surgery for rectal neoplasm.All patients underwent transanal endoscopic microsurgery for rectal neoplasm.Size and pathology of lesion, length of procedure, hospital stay, estimated blood loss, margin status, and complications were the outcomes measured.Twenty-eight patients who underwent transanal endoscopic microsurgery had definitively documented intraperitoneal entry and anastomosis. Median follow-up was 12 months (range, 0.5-111 months). There were no operative mortalities. Procedure-related complications included urinary retention (11%), fever (11%), and fecal seepage (4%). Four patients (14%) had positive margins on final pathology. One patient (3%) required abdominal exploration for an anastomotic leak but did not require diversion.Although this study analyzes prospectively collected data, it is nonetheless a retrospective analysis that can introduce bias. Because this is a single-center study with a relatively homogenous population, the results may not be generalizable. Our sample size may also be underpowered to detect clinically significant outcomes.Transanal endoscopic microsurgery with intraperitoneal anastomosis can be safely performed without fecal diversion by experienced surgeons.

Sacrocolpopexy with rectopexy is advocated for combined rectal and vaginal prolapse, but limited outcome data have been reported.The purpose of this study was to evaluate the indications and outcomes of sacrocolpopexy and rectopexy by comparing pre- and postoperative function and quality of life.A retrospective review of prospectively collected data was performed of all patients undergoing sacrocolpopexy and rectopexy at our institution from 2004 to 2011.Preoperatively, all patients underwent physiology testing and completed 4 validated questionnaires assessing bowel symptom severity and associated quality of life. Patients completed the same questionnaires in 2012.A total of 110 women (median age, 55 years; range, 28-88) underwent a sacrocolpopexy and rectopexy, 33 with concomitant hysterectomy. All patients had rectal prolapse (n = 96) or rectal intussusception (n = 14), and each also had either enterocele (n = 86) or vaginal prolapse (n = 48). Rectal prolapse with enterocele was the most common presentation (n = 75). Previous surgery included rectal prolapse repair (21%) and hysterectomy (57%). Complications included presacral bleeding (n = 2), ureteral injury (n = 2), wound infection (n = 8), and pulmonary embolism (n = 2). There were no mortalities. Fifty-two patients completed the follow-up questionnaires, with a median follow-up of 29 (range, 4-90) months, and preoperative surveys were available in 30 of these patients. Preoperatively, 93% reported constipation; 82% reported resolution or improvement postoperatively. Constipation severity, measured with the Patient Assessment of Constipation Symptom Questionnaire, demonstrated improvement (1.86-1.17; p0.001). Fecal incontinence severity scores (Fecal Incontinence Severity Index) improved (39-24; p0.01), and 82% of incontinent patients reported cure or improvement. Quality-of-life scores also improved significantly. No patient developed recurrent rectal prolapse.This was a retrospective review, and the response rate to questionnaires was limited.Sacrocolpopexy and rectopexy for combined middle and posterior compartment prolapse is a safe procedure, with low risk for recurrence, and improves bowel function and quality of life in most patients.

The ligation of the intersphincteric fistula tract procedure has been reported to have high cure rates, with minimal impairment of continence.The aim of this study was to evaluate the success rates and functional outcome after the ligation of the intersphincteric fistula tract procedure.This study was performed as a retrospective review.The study was conducted at the Division of Colon and Rectal Surgery, University of Minnesota and at affiliated hospitals in Minneapolis and St. Paul, Minnesota, between March 2007 and September 2011.Ninety-three patients with transsphincteric cryptoglandular anal fistula were included.Ligation of the intersphincteric fistula tract procedure was performed.Failure was defined as persistent or recurrent drainage, air leakage from a patent external opening, or intersphincteric incision or reoperation for recurrent fistula. Success was defined as healing of the external fistula opening and intersphincteric incision. Patients were followed up with a questionnaire to assess the recurrence rate and the Wexner incontinence score.The median follow-up time for was 19 months (range, 4-55). Thirty patients (32%) had a history of previous surgery for their fistula. The success rate of fistula healing was 40% after the first ligation of the intersphincteric fistula tract procedure. When including patients with repeat ligation of the intersphincteric fistula tract and subsequent intersphincteric fistulotomy after ligation of the intersphincteric fistula tract repair, the success rates were 47% and 57%. Patients with successful fistula closure reported a mean Cleveland Clinic Florida Fecal Incontinence score of 1.0 (SD 2.3). No predictor for successful fistula closure was found.Retrospective design, limited accuracy of diagnosing fistula failure, and lack of baseline continence were limitations of this study.The present study indicates that the ligation of the intersphincteric fistula tract procedure for transsphincteric fistulas has a significant risk for failure but good functional outcome in patients with no recurrence.

Objective: The aim of the present analysis was to report on the relationship between long-term improvement in quality of life (QOL) and fecal incontinence (FI) severity and long-term reduction in FI episodes after sacral nerve stimulation (SNS) or sacral neuromodulation. Methods: Patients who met inclusion/exclusion criteria, and initially had more than 2 FI episodes per week, were offered SNS therapy. Patients with 50% or higher reduction in FI during a 2-week test period were implanted with a neurostimulator (InterStim; Medtronic, Minneapolis, Minn). Assessments were completed by patients at baseline and at 3, 6, and 12 months after implant, and annually thereafter. The present report includes data from the 4-year postimplant follow-up. Results: A total of 133 patients underwent test stimulation with a 90% success rate, and as a result, 120 (110 females) with a mean age of 60.5 years and a mean duration of FI of 6.8 years received longterm implantation. Of them, 78 patients completed all or part of the 4

The aim of this was to define 30-day outcomes of patients treated with colectomy and en bloc pancreatectomy for invasive colon cancer.ACS NSQIP was used to identify patients who underwent colectomy and pancreatectomy concomitantly (n = 65) for colon carcinoma. Patients with en bloc pancreatectomy were compared to a propensity score-matched control group for 30-day outcomes.Sixteen patients underwent a pancreaticoduodenectomy with colectomy and 49 patients underwent a distal pancreatectomy with colectomy. There were 195 matched control patients. En bloc pancreatectomy (Whipple vs. distal pancreatectomy vs. control) patients had longer OR times (390 vs. 265 vs.137 min) and length of postoperative stay (12 vs. 10 vs. 6 days). The frequency of pulmonary complications (31.3% vs. 36.7% vs. 3.6%), blood transfusions (2.9 vs. 1.7 vs. 0.3 U), wound dehiscence, (18.8% vs. 6.12% vs.0.5%) and surgical site infection (43.5% vs. 34.7% vs.14.9%) were substantially higher in the pancreatectomy group (p0.05). There were no statistically significant differences in 30-day mortality between the pancreatectomy group and the control group (6.3% vs. 0% vs. 1.5% p = 0.25)Perioperative outcomes with en bloc pancreatectomy and colectomy include increased pulmonary complications, blood transfusions, wound complications, and length of stay compared to patients treated with colectomy alone for colon cancer.

Aim Background Obesity rates are rapidly growing in the developed world. While upper gastrointestinal disturbances and urinary incontinence are independently associated with obesity, the relationship between obesity and defecatory dysfunction is less well defined. Objectives To summarize the literature on faecal incontinence, diarrhoea and constipation in obese patients and its effects of bariatric surgery. Method Search strategy A Medline search was carried out on articles published from January 1966 to March 2010. Selection criteria Original articles on adult obese or morbidly obese patients were identified, including results following bariatric surgery that reported faecal incontinence, diarrhoea or constipation. Other forms of pelvic floor dysfunction were excluded. Main outcome measures included faecal incontinence, diarrhoea and constipation rates and their severity in obese patients and following bariatric surgery. Results Twenty studies reported defecatory outcomes in obese patients (n = 14) and after bariatric surgery (n = 6). While constipation rates were similar, the rates of faecal incontinence and diarrhoea were higher in obese patients compared with non-obese patients. The exact rates of these conditions, and the correlations between body mass index (BMI) and faecal incontinence, diarrhoea and constipation, were not clear. Faecal incontinence improved after Roux-en-Y gastric bypass in studies with preoperative data. The effects of bariatric surgery on diarrhoea were unclear. Conclusion Few studies have assessed the correlations between obesity and defecatory function and the effect of bariatric surgery. Studies were often not well controlled and used non-uniform instruments to assess bowel function. Obesity appears to be correlated with higher rates of faecal incontinence and diarrhoea. The effects of bariatric surgery on these conditions are not well defined. Well-controlled studies correlating outcome with physiological pelvic floor function are needed.

Surgical management of pelvic floor disorders depends on a comprehensive understanding of the structural integrity and function of the pelvic floor. For visualizing this region, ultrasonography has emerged as a procedure that is relatively easy to perform, cost-effective and widely available. In this review, pelvic floor ultrasonography, including two-dimensional (2D), three-dimensional (3D) and 4D imaging as well as transvaginal, endoanal and transperineal techniques, is discussed from a global and multicompartmental perspective, rather than using a compartmentalized approach. The role of the different sonographic modalities in the major disorders of the pelvic floor-urinary and fecal incontinence, pelvic organ prolapse and obstructed defecation syndrome-is evaluated critically.

Summary Background Injection of a bulking agent in the anal canal is an increasingly used treatment for faecal incontinence, but efficacy has not been shown in a controlled trial. We aimed to assess the efficacy of injection of dextranomer in stabilised hyaluronic acid (NASHA Dx) for treatment of faecal incontinence. Methods In this randomised, double-blind, sham-controlled trial, patients aged 18–75 years from centres in USA and Europe were randomly assigned (2:1) to receive either transanal submucosal injections of NASHA Dx or sham injections. Randomisation was stratified by sex and region in blocks of six, and managed with a computer generated, real-time, web-based system. Patients and investigators were masked to assignment for 6 months when the effect on severity of faecal incontinence and quality of life was assessed with a 2-week diary and clinical assessments. The primary endpoint was response to treatment based on the number of incontinence episodes. A response to treatment was defined as a reduction in number of episodes by 50% or more. Patients in the active treatment group are still being followed up. This trial was registered with ClinicalTrials.gov, number NCT00605826. Findings 278 patients were screened for inclusion, of whom 206 were randomised assigned to receive NASHA Dx (n=136) or sham treatment (n=70). 71 patients who received NASHA Dx (52%) had a 50% or more reduction in the number of incontinence episode, compared with 22 patients who received sham treatment (31%; odds ratio 2·36, 95% CI 1·24–4·47, p=0·0089). We recorded 128 treatment-related adverse events, of which two were serious (1 rectal abscess and 1 prostatic abscess). Interpretation Anal injection of NASHA Dx is an effective treatment for faecal incontinence. A refinement of selection criteria for patients, optimum injected dose, ideal site of injection, and long-term results might further increase the acceptance of this minimally invasive treatment. Funding Q-Med AB.

This study investigates the association between endoanal ultrasonography and anorectal manometry in relation to anal incontinence after primary repair of obstetric sphincter injury in primiparous, premenopausal women.The study population of this nested case-control study comprised 108 women who had previously been part of a randomized controlled trial comparing immediate with delayed primary repair of obstetric sphincter injuries, and who had been evaluated by anorectal manometry and endoanal ultrasound 1 year after their repair. Twenty cases and 88 controls were defined. Cases were defined as having a score greater than 2 on the Pescatori incontinence scale. Controls had a score of 2 or less. Ten obstetric, 9 ultrasonographic, and 7 manometric variables were studied.Of the manometric variables, volume of first sensation and volume of first urge proved to be associated with anal incontinence at univariate statistical analysis. Volume of first sensation remained independently associated with anal incontinence after multivariate analysis. In addition, age, degree of tear, duration of second stage of labor, and a distal scar at ultrasound proved to be independently associated with anal incontinence.Impaired rectal sensation at anorectal manometry and a distal scar at endoanal ultrasonography are associated with anal incontinence 1 year after primary sphincter repair in primiparous women. Additional studies need to evaluate whether these findings are associated with increased risk of anal incontinence in women that are continent 1 year after primary repair.

Aim Surgical repair of recto-vaginal fistula (RVF) in Crohn’s disease (CD) has been associated with high rates of failure. The aim of this study was to compare the outcome in patients with CD who underwent RVF surgery with or without infliximab infusion. Method A retrospective review was carried out of 51 consecutive patients with CD treated for a symptomatic RVF between March 1998 and December 2004. Results Fifty-one patients (mean age 39 years) underwent 65 procedures, including seton drainage (n = 35), advancement flap (n = 8), fibrin glue injection (n = 8), transperineal repair (n = 6), collagen plug placement (n = 4) and bulbocavernosus flap (n = 4). All patients were on medical treatment at the time of surgery and 26 patients had received preoperative infliximab treatment (minimum of three infusions, 5 mg/kg). Ten patients underwent preoperative diversion. At a mean follow up of 38.6 months, 27 fistulas (53%) had healed and 24 (47%) had recurred. Fistula healing occurred in 60% of patients treated with preoperative diversion, whereas 51% of nondiverted repairs were successful. Neither active proctitis nor infliximab therapy significantly affected fistula healing. Fourteen (27%) patients eventually required proctectomy. Conclusion RVF in CD is difficult to treat. Failure rates are significant despite repeated surgical interventions and concomitant medical treatment.

Purpose This study was designed to analyze the incidence, management, and outcome of pouch sinuses after ileal pouch-anal anastomosis at one institution. Methods We identified 282 ileal pouch-anal anastomosis patients between 1992 and 2002 who had a pouchogram before planned ileostomy closure. The management and outcome of patients with pouchograms revealing pouch sinuses were reviewed. Results Twenty-two patients (7.8 percent) had a pouch sinus at pouchogram. Nineteen patients were observed and underwent repeat pouchogram. Of these, ten had sinus resolution (mean, 3.6 months) and underwent successful ileostomy closure. Eight patients underwent examination under anesthesia +/- sinus debridement. Six of these patients had subsequent pouchograms with five showing sinus resolution. The patient without resolution was not reversed. Of the eight patients who underwent examination under anesthesia +/- debridement, seven underwent ileostomy closure (mean, 4.9 months), with healing in six and pelvic sepsis in one. Four patients underwent successful ileostomy takedown despite persistent sinus. Overall, 21 of the 22 pouch sinus patients underwent ileostomy closure and only 1 had postoperative pelvic sepsis. Conclusions Pouch sinuses after ileal pouch-anal anastomosis with ileostomy are uncommon. Most heal within six months. The majority of patients with sinuses eventually undergo successful ileostomy closure. Pelvic septic complications are rare but can occur despite sinus healing on pouchogram.

Anal fistulas that involve a significant amount of sphincter may be difficult to treat without compromising continence function. In this study, we evaluated our experience with the Surgisis anal fistula plug, which was recently reported to be successful in80 percent of patients with complex fistulas.We retrospectively collected patient and fistula characteristics, procedure details, and follow-up information for all patients treated with the anal fistula plug at our institution from January 2006 through April 2007. The outcome was considered successful if the external opening was closed and if the patient had no drainage at the last follow-up. Using multivariate statistics, we analyzed the relationship between anal fistula plug success and several key variables.From January 2006 through April 2007, 47 patients with 49 complex anal fistulas underwent 64 anal fistula plug procedures. The median follow-up time for patients who were considered healed was 6.5 (range, 3-11) months. The success rate was 31 percent per procedure and 43 percent per patient. An increased amount of external sphincter involvement was associated with a higher failure rate (P0.05).In our early experience with the anal fistula plug, 43 percent of patients with complex anal fistulas were successfully treated. Patients with less external sphincter involvement were more likely to heal.

We describe the relationship between anorectal manometry, fecal incontinence severity, and findings at endoanal ultrasound.A total of 351 women completed the Fecal Incontinence Severity Index, underwent anorectal manometry, and endoanal ultrasound. Severity index and manometry pressures in 203 women with intact sphincters on ultrasound were compared with pressures in 148 women with sphincter defects. Relationships between resting and squeeze pressures, severity index, and size of sphincter defects were evaluated.Mean severity index in patients with and without sphincter defect was 35.7 vs. 36.7 (not significant). Worsening index correlated with worsening mean and maximum resting pressure (P0.0001). Differences were observed in mean and maximum resting pressure between the patients with and without sphincter defects (26.6 vs. 37.2, P0.0001; 39.4 vs. 51.7, P0.001). Resting pressures correlated with the sizes of defect (P0.0001).Patients with and without sphincter defects had similar severity scores, but patients with defects had a significant decrease in resting pressures. Patients with larger sphincter defects had lower severity scores and resting pressures. Until a manometry cutoff can be set to discriminate between absence and presence of defects, both manometry and ultrasound should be offered to patients with history of anal trauma.

Despite its widespread use, the role of local excision for early rectal cancer as a curative therapy remains controversial. Studies are often plagued with low patient numbers, limited follow-up, or heterogeneous populations. In addition, problems with inaccurate staging, inadequate resection margins, and patient selection have limited the ability to interpret, compare, and generalize results. This article will focus on reported outcomes of local excision for early rectal cancer and discuss suggested guidelines.

Difficulties with bowel function are common and may be due to several causes including slow colonic transit and obstructed defecation. The anatomical and pathophysiological changes associated with these conditions are varying, often incompletely understood, and in many cases have limited treatment outcomes. Patients present with variable complaints and have previously tried a plethora of over-the-counter medications in an effort to relieve their symptoms. Physicians need an organized approach to manage these patients optimally. Improvements over the past few years in our understanding of the complex process of defecation, along with the increasing use of radiological and anorectal physiology studies, have led to improved treatment results.

Defecation problems occur in patients of all ages, but are more prevalent in the elderly, postpartum women, and patients with chronic and debilitating medical conditions. Most of the time, these problems respond to medical therapy and nonsurgical options, but it is not uncommon for patients to require surgical intervention. Sacral nerve stimulation (SNS) presents an alternative for patients with bowel dysfunction combining proven therapeutic benefits and limited surgical risks. Here we describe the common indications for SNS, patient selection, technical details of the procedure, published outcomes, and complications that can arise. Based on our review, SNS is an effective treatment option for fecal incontinence and may reduce the patients' clinical symptoms and help restore their quality of life. Future research studies may expand the role of this modality for other bowel disorders.

BACKGROUND Overall, the incidence of colorectal cancer appears to be stable or diminishing. However, based on our practice pattern, we observed that the incidence of rectal cancer in patients under 40 is increasing and may be associated with a prominence of signet-ring cell histology. OBJECTIVE The aim of this study was to verify the rising trend in rectal cancer in patients under 40 and describe the histology prominent in that cohort. DESIGN This is a retrospective cohort study. SETTING AND PATIENTS We performed a retrospective cohort study of all patients diagnosed with rectal adenocarcinoma from 1980 to 2010 using the Surveillance, Epidemiology, and End Results cancer registry. MAIN OUTCOME MEASURES Rectal cancer incidence, histology, and associated staging characteristics were the primary outcomes measured. RESULTS Although the incidence of rectal cancer for all ages remained stable from 1980 to 2010, we observed an annual percent change of +3.6% in the incidence of rectal cancer in patients under 40. The prevalence of signet cell histology in patients under 40 was significantly greater than in patients over 40 (3% vs 0.87%, p < 0.01). A multivariate regression analysis revealed an adjusted odds ratio of 3.6 (95% CI, 2.6-5.1) for signet cell histology in rectal adenocarcinoma under age 40. Signet cell histology was also significantly associated with a more advanced stage at presentation, poorly differentiated tumor grade, and worse prognosis compared with mucinous and nonmucinous rectal adenocarcinoma. LIMITATIONS The study was limited by its retrospective nature and the information available in the Surveillance, Epidemiology, and End Results database. CONCLUSIONS Despite a stable incidence of rectal cancer for all ages, the incidence in patients under 40 has quadrupled since 1980, and cancers in this group are 3.6 times more likely to have signet cell histology. Given the worse outcomes associated with signet cell histology, these data highlight a need for thorough evaluation of young patients with rectal symptoms.

Ziel dieser Studie war es, die Pravalenz von Genitalprolaps-Operationen und Harninkontinenz bei Patientinnen, die wegen eines Rektumprolaps operiert worden waren, im Vergleich zu einer entsprechenden Kontrollgruppe ohne Rektumprolaps zu untersuchen. 52 Patientinnen mit Rektumprolaps-Operationen in der Vorgeschichte sowie 200 willkurlich ausgewahlte, alters- und geschlechtsangepasste Kontrollpersonen ohne Rektumprolaps erhielten einen ausfuhrlichen Gesundheitsfragebogen. Die Rucklaufquote betrug in der Patientinnengruppe 48 von 52 (92%) und in der Kontrollgruppe 165 von 200 (82%). Ein Rektumprolaps war mit einem gesteigerten Operationsrisiko wegen eines Uterusprolaps (Odds-Ratio = 3,1; 95%-Konfidenzintervall = 1,4–6,9) und eines Vaginalprolaps (Odds-Ratio = 3,2; 95%-Konfidenzintervall = 1,3–7,8) assoziiert. Das mittlere Alter bei einer Hysterektomie wegen Uterusprolaps betrug 54,7 Jahre in der Patientinnengruppe, verglichen mit 62,6 Jahren in der Kontrollgruppe (p < 0,01). Das mittlere Alter bei Vaginalprolaps-Operation betrug 60,2 Jahre in der Patientinnengruppe, verglichen mit 66,6 Jahren in der Kontrollgruppe (p < 0,05). Es fanden sich keine signifikanten Unterschiede zwischen den Gruppen bezuglich einer hoheren Pravalenz oder des Alters beim ersten Auftreten einer Harninkontinenz. Die Ergebnisse zeigen einen starken Zusammenhang zwischen einer rektalen und genitalen Prolapsoperation. Dies legt nahe, dass der Diagnose eines Rektumprolaps, der operiert werden soll, eine multidisziplinare Beckenboden-Untersuchung folgen muss.

Data supporting an increased risk of colorectal cancer in patients with Crohn’s colitis are inconsistent. Despite this, clinical recommendations regarding colonoscopic screening and surveillance for patients with Crohn’s colitis are extrapolated from chronic ulcerative colitis protocols. The primary aim of our study was to determine the incidence of dysplasia and carcinoma in pathology specimens of patients undergoing segmental or total colectomy for Crohn’s disease of the large bowel. In addition, we sought to identify risk factors associated with the development of dysplasia and carcinoma. We performed a retrospective review of all patients operated on at our institution for Crohn’s colitis between January 1992 and May 2004. Data were retrieved from patient charts, operative notes, and pathology reports. Logistic regression was used to model the probability of having dysplasia or adenocarcinoma. Two hundred twenty-two patients (138 females) who underwent surgical resection for the treatment of Crohn’s colitis were included in the study. Mean age at surgery was 41 (range, 15–82) years and the mean duration of disease was 10 (range, 0–53) years. There were five cases of dysplasia (2.3 percent) and six cases of adenocarcinoma (2.7 percent). Three patients with dysplasia and one with adenocarcinoma were diagnosed on preoperative colonoscopy; while the other cases were discovered incidentally on pathologic examination of resected specimens. Factors associated with the presence of dysplasia or adenocarcinoma included older age at diagnosis (38.2 vs. 30.3 years, P = 0.02), longer disease duration (16.0 vs. 10.1 years, P = 0.05), and disease extent (90 percent extensive vs. 59 percent limited, P = 0.05). Patients with severe Crohn’s colitis requiring surgery are at significant risk for developing dysplasia and adenocarcinoma, particularly when diagnosed at an older age, after longer disease duration, and with more extensive colon involvement.

Recurrent rectal prolapse is an unresolved problem and the optimal treatment is debated. This study was designed to review patterns of care and outcomes in a large cohort of patients after surgery for recurrent prolapse. From 685 patients who underwent operative repair for full-thickness external rectal prolapse, we identified 78 patients (70 females; mean age, 66.9 years) who underwent surgery for recurrence. We reviewed the subsequent management and outcomes for these 78 patients. Mean interval to their first recurrence was 33 (range, 1–168) months. There were significantly more re-recurrences after reoperation using a perineal procedure (19/51) compared with an abdominal procedure (4/27) for their recurrent rectal prolapse (P = 0.03) at a mean follow-up of nine (range, 1–82) months. Patients undergoing abdominal repair of recurrence were significantly younger than those who underwent perineal repair (mean age, 58.5 vs. 71.5 years; P < 0.01); however, there was nosignificant difference between the two groups with regard to the American Society of Anesthesiologists classification (P = 0.89). Eighteen patients had surgery for a second recurrence, with perineal repairs associated with higher failure rates (50 vs. 8 percent; P = 0.07). Finally, when combining all repairs, the abdominal approach continued to have significantly lower recurrence rates (39 vs. 13 percent; P < 0.01). The re-recurrence rate after surgery for recurrent rectal prolapse is high, even at a relatively short follow-up interval. Our data suggest that abdominal repair of recurrent rectal prolapse should be undertaken if the patient's risk profile permits this approach.

To prospectively evaluate clinical outcome of rectocele repair using xenograft 3 years after surgery.Twenty-three patients who completed evaluation preoperatively and 1 year after surgery were assessed at a 3-year follow-up. Clinical examination was performed preoperatively, and at the 1- and 3-year follow-ups, with the pelvic organ prolapse quantification system. Symptom assessment was performed with a validated bowel function questionnaire including questions on sexual function.There were no graft-related complications during the 3 years following surgery. Preoperatively, all patients had stage II prolapse of the posterior vaginal wall and a rectocele verified at defecography. At the 1-year follow-up, 11 of 29 patients (38%) had rectocele of stage II or more, and 4 patients were reoperated. At 3-year follow-up 7 of 23 patients (30%) had rectocele of stage II or more. When including the 4 early anatomical recurrences, a total of 11 of 27 patients (41%) had rectocele of stage II or more at 3-year follow-up. Preoperatively, all patients reported varying degrees of rectal emptying difficulties and symptoms of bowel dysfunction. There was a significant decrease in rectal emptying difficulties (P.01), sense of incomplete evacuation (P.01), need for manually assisted defecation (P.05), and symptoms of pelvic heaviness (P.001) at the 3-year follow-up compared with preoperatively. Cure of rectal emptying difficulties was reported by fewer than 50% of patients. There were no significant changes in anal incontinence scores or symptoms of sexual dysfunction at the 3-year follow-up compared with preoperatively.Rectocele repair using porcine dermal graft was associated with an unsatisfactory anatomical cure rate and persistent bowel-emptying difficulties in the majority of patients 3 years postoperatively.II-3.

This study was designed to evaluate rectocele repair using collagen mesh. 32 female patients underwent surgical repair using collagen mesh. Outcome was assessed in 29 patients and preoperative assessment included standardized questionnaire, clinical examination, and defecography. At the six-month follow-up, patients answered a standardized questionnaire and underwent clinical examination. At the 12-month follow-up, patients answered a standardized questionnaire, underwent clinical examination, and defecography. Preoperatively, 26 patients had a Stage II and 3 patients had a Stage III rectocele. At the 6-month follow-up, five patients had rectocele ≥ Stage II (P < 0.001) and at the 12-month follow-up, seven patients had rectocele ≥ Stage II (P < 0.001) at clinical examination. At the preoperative defecography, all patients presented a rectocele. At the 12-month defecography, 14 patients had no rectocele (P < 0.001) and 15 had a rectocele. At the six-month follow-up, there was a significant decrease in rectal emptying difficulties, need of digital support of the posterior vaginal wall at defecation, and defecation frequency. At the 12-month follow-up, symptom improvement remained, but was less pronounced. Rectocele repair using collagen mesh improved anatomic support, but there is a substantial risk for recurrence with unsatisfactory anatomic and functional outcome one year after surgery. Rectocele repair using mesh was not associated with an increased risk of dyspareunia. Rectocele repair using biomaterial mesh reinforcement needs further evaluation before adopted into clinical practice.