Published online Dec 6, 2020. doi: 10.12998/wjcc.v8.i23.5976
Peer-review started: June 27, 2020
First decision: September 23, 2020
Revised: September 26, 2020
Accepted: October 13, 2020
Article in press: October 13, 2020
Published online: December 6, 2020
Processing time: 155 Days and 21.9 Hours
Abdominal ventral rectopexy (AVR) with colectomy is controversial in the treatment of obstructed defecation syndrome (ODS). Literature data on this technique are very limited.
ODS is the most common type of chronic constipation. In patients with severe symptoms of constipation, reduced quality of life, and conservative treatment have failed, surgery should be considered. Many different surgical procedures have been reported, but no optimal procedure has been identified for all patients to date. It is controversial whether an additional colon resection in rectopexy is required. Laparoscopic ventral rectopexy has become a salutatory procedure with better functional outcomes in recent years, and it achieved an 80% improvement in constipation. Therefore, whether AVR combined with an additional colon resection can provide better functional results in the treatment of ODS has not been reported and is worthy of exploration.
The research objectives were to evaluate the efficacy and safety of AVR with colectomy in selected patients with ODS. The primary objectives were improvement in functional outcomes determined by constipation symptoms and quality of life assessed by the Wexner Constipation Score, ODS score and the Patients Assessment of Constipation Quality of Life score through patient-self comparison pre- and post-operatively. Secondary objectives were operating time, postoperative length of stay, complications and mortality, improvement of pelvic floor structure, and patient satisfaction.
Consecutive patients who received AVR with colectomy for ODS between January 2016 and December 2017 in our department were identified prospectively. Data regarding patient demographics, perioperative surgical results and postoperative follow-up outcomes were obtained prospectively. Patients with ODS who conformed to the Rome III criteria of functional constipation and who failed maximal conservative treatments including biofeedback and medical therapy were eligible. These patients had severe constipation symptoms [Wexner Constipation Score (WCS) > 15 and ODS score > 10], and high grade (III/IV) full-thickness rectal intussusception, along with pelvic floor anatomic abnormalities. All operations were performed by the same surgical team to ensure quality control (Figure 1). Statistical analyses were performed using SPSS 24.0 (SPSS, Chicago, IL, United States). The Mann–Whitney U test was used to compare the preoperative scores with the follow-up scores.
Perioperative outcomes: Six patients underwent robotic-assisted and laparoscopic-assisted ventral mesh rectopexy with colectomy. All patients were diagnosed as having grade III and IV internal rectal prolapse along with pelvic organ prolapse, deep cul-de-sac, and redundant sigmoid colon. There was no conversion to open procedure and no postoperative mortality. No urinary retention, wound infection, prolonged ileus, pelvic infection, and anastomosis leakage occurred. One patient who developed mesh erosion into the rectum complained of pelvic pain and was examined by pelvic magnetic resonance imaging and proctoscopy at 15 mo postoperatively. The patient achieved complete symptomatic remission after the mesh was removed transanally by colonoscopy. Functional outcomes: All patients completed 36 mo follow-up after surgery. The mean WCS before surgery was 18.6 (range 15-23). The mean WCS improved to 6.7 (range 3-10) at 36 mo. Six patients showed significant improvement in constipation after surgery compared with the preoperative condition (P < 0.05). The mean ODS score decreased from 20.7 (range 16-25) preoperatively to 7 (range 2-10) at the end of follow-up (P < 0.05, respectively). The mean Patients Assessment of Constipation Quality of Life score improved from 57.5 (range 42-69) to 23.3 (range 13-38) (P < 0.05, respectively). Six patients were satisfied with the surgery and had no regrets regarding surgical treatment. There was no recurrence or novel constipation after surgery. None of the patients used laxative medication.
The postoperative results and long-term functional outcomes are satisfactory for selected patients with ODS. Robotic and laparoscopic-assisted ventral rectopexy with colectomy is a safe and effective procedure. However, comprehensive preoperative evaluation and careful patient selection are essential.
This was the first study to explore AVR with colectomy for the treatment of ODS. The results showed that these patients achieved satisfactory functional results during a 3-year follow-up, despite the small number of cases. Although the present study has some limitations, we will increase the number of patients and include a control group of AVR without colectomy in a subsequent study, which could be more powerful in proving whether colectomy is necessary.