P Bachoo1, M Brazzelli, A Grant. 1. Health Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, Aberdeenshire, UK, AB25 2ZD. paul@pbachoo.freeserve.co.uk
Abstract
BACKGROUND: Complete rectal prolapse is a debilitating condition, which affects both the very young and the elderly and can cause faecal incontinence. The range of surgical methods available to correct the underlying anal sphincter or pelvic floor defects in complete rectal prolapse poses the question about the choice of the best operation. OBJECTIVES: To determine the effects of surgery on the treatment of rectal prolapse in adults. The following specific issues have been addressed: I. Whether surgical intervention is better than no treatment; II. Whether an abdominal approach to surgery is better then a perineal approach; III. Whether one method for performing rectopexy is better than another; IV. Whether laparoscopic access is better than open access for surgery; V. Whether resection should be included in the procedure. SEARCH STRATEGY: We searched the Cochrane Incontinence Group trials register, the Cochrane Colorectal Cancer Group trials register, the Cochrane Controlled Trials Register (Issue 2, 1999), Medline (up to March 1999), Embase (1998 up to January 1999), Sigle (1980 up to December 1996), Biosis (1998 up to March 1999), SCI (1998 up to March 1999), ISTP (1982 up to March 1999) and the reference lists of relevant articles. We hand searched the British Journal of Surgery 1995-8, and the Diseases of the Colon and Rectum 1995-8. We also searched the proceedings of the Association of Coloproctology, meeting 1999. Date of the most recent searches: March 1999. SELECTION CRITERIA: All randomised or quasi-randomised trials of surgery in the management of rectal prolapse. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected studies from the literature, extracted data and assessed the methodological quality of eligible trials. The three primary outcome measures were number of patients with recurrent rectal prolapse, or residual mucosal prolapse or faecal incontinence. MAIN RESULTS: Eight trials were included with a total of 264 participants. No trial included a group receiving no treatment, or anal encirclement, or Delormes procedure, or laparoscopic suture rectopexy, or laparoscopic resection rectopexy. One trial (20 participants) compared both perineal and abdominal resection rectopexy with pelvic floor repair; four trials (175 participants) compared different types of open rectopexy techniques; one trial (21 participants) compared laparoscopic with open mesh rectopexy; and two trials included comparisons between open resection rectopexy and rectopexy alone. In all comparisons data were few. There were no detectable differences in recurrent prolapse between abdominal and perineal approaches, although there was a suggestion that residual faecal incontinence was less common after abdominal surgery. There were no detectable differences between the methods used for fixation during rectopexy. Division, rather than preservation, of the lateral ligaments was associated with less recurrent prolapse but more post-operative constipation, although these findings were found in small numbers. There were too few data with which to compare laparoscopic with open surgery. Bowel resection during rectopexy was associated with lower rates of constipation, but again numbers were small. REVIEWER'S CONCLUSIONS: The small number of relevant trials identified, and their small sample sizes together with other methodological weaknesses severely limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical operations. Larger rigorous trials are needed to improve the evidence with which to define optimum surgical treatment.
BACKGROUND: Complete rectal prolapse is a debilitating condition, which affects both the very young and the elderly and can cause faecal incontinence. The range of surgical methods available to correct the underlying anal sphincter or pelvic floor defects in complete rectal prolapse poses the question about the choice of the best operation. OBJECTIVES: To determine the effects of surgery on the treatment of rectal prolapse in adults. The following specific issues have been addressed: I. Whether surgical intervention is better than no treatment; II. Whether an abdominal approach to surgery is better then a perineal approach; III. Whether one method for performing rectopexy is better than another; IV. Whether laparoscopic access is better than open access for surgery; V. Whether resection should be included in the procedure. SEARCH STRATEGY: We searched the Cochrane Incontinence Group trials register, the Cochrane Colorectal Cancer Group trials register, the Cochrane Controlled Trials Register (Issue 2, 1999), Medline (up to March 1999), Embase (1998 up to January 1999), Sigle (1980 up to December 1996), Biosis (1998 up to March 1999), SCI (1998 up to March 1999), ISTP (1982 up to March 1999) and the reference lists of relevant articles. We hand searched the British Journal of Surgery 1995-8, and the Diseases of the Colon and Rectum 1995-8. We also searched the proceedings of the Association of Coloproctology, meeting 1999. Date of the most recent searches: March 1999. SELECTION CRITERIA: All randomised or quasi-randomised trials of surgery in the management of rectal prolapse. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected studies from the literature, extracted data and assessed the methodological quality of eligible trials. The three primary outcome measures were number of patients with recurrent rectal prolapse, or residual mucosal prolapse or faecal incontinence. MAIN RESULTS: Eight trials were included with a total of 264 participants. No trial included a group receiving no treatment, or anal encirclement, or Delormes procedure, or laparoscopic suture rectopexy, or laparoscopic resection rectopexy. One trial (20 participants) compared both perineal and abdominal resection rectopexy with pelvic floor repair; four trials (175 participants) compared different types of open rectopexy techniques; one trial (21 participants) compared laparoscopic with open mesh rectopexy; and two trials included comparisons between open resection rectopexy and rectopexy alone. In all comparisons data were few. There were no detectable differences in recurrent prolapse between abdominal and perineal approaches, although there was a suggestion that residual faecal incontinence was less common after abdominal surgery. There were no detectable differences between the methods used for fixation during rectopexy. Division, rather than preservation, of the lateral ligaments was associated with less recurrent prolapse but more post-operative constipation, although these findings were found in small numbers. There were too few data with which to compare laparoscopic with open surgery. Bowel resection during rectopexy was associated with lower rates of constipation, but again numbers were small. REVIEWER'S CONCLUSIONS: The small number of relevant trials identified, and their small sample sizes together with other methodological weaknesses severely limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical operations. Larger rigorous trials are needed to improve the evidence with which to define optimum surgical treatment.