Laparoscopic ventral mesh rectopexy for obstructive defecation syndrome: Follow-up in the Indian population.

CONTEXT: Obstructive defecation syndrome (ODS) is a poorly understood cause of constipation. In selected patients not responding to conservative management, surgical options may be offered. Laparoscopic ventral mesh rectopexy (LVMR) is another surgical option which gained popularity in the past decade. AIM: This study aims to identify the efficacy of LVMR in the Indian population. SETTING AND
DESIGN: It is a retrospective analysis of prospectively collected data of patients who underwent LVMR from January 2015 to January 2017 at a tertiary centre in India. SUBJECTS AND METHODS: Thirty patients fulfilled the inclusion criteria. Patients were periodically followed for 2 years. Pre- and post-operative modified Longo's ODS scores were recorded and compared. Furthermore, other complications were noted and evaluated. STATISTICAL ANALYSIS USED: Relevant statistical tests were used to analyse the collected data.
RESULTS: Thirty patients (28 females, 2 males, mean age: 52.4 years) underwent LVMR for ODS due to anatomical abnormality like rectorectal intussusceptions (RRIs) (36.7%), rectocele (13.3%), or combined RRI with rectocele (50%). The mean pre-operative modified Longo's ODS score was 23.17 ± 4.82 which decreased to 2.37 ± 1.59 at the end of 6 months and 1.23 ± 1.14 and 1.57 ± 1.14 at the end of 12 months and 2 years, respectively. The mean modified Longo's ODS score showed a significant fall of 94.7% at 12-month follow-up and 93.2% fall on 2-year follow-up. The mean operative time was 115 min and the average hospital stay of patients who underwent LVMR was 3.26 days.
CONCLUSION: LVMR is a safe surgical procedure with minimal complications and good functional results for ODS patients due to rectal anatomical abnormality. Further larger studies are required to decide the best treatment modality for ODS.

INTRODUCTION

With an estimated prevalence of 20%, constipation remains one of the most common gastrointestinal disorders.[1] Constipation can be broadly divided into two main categories: primary functional constipation or secondary to systemic disorders. Primary functional constipation can be due to colonic inertia, constipation-predominant irritable bowel syndrome or obstructive defecation syndrome (ODS).[2] ODS is common but poorly understood complex multifactorial condition characterised by impaired ability to evacuate despite normal desire to defecate and requires prolonged strenuous attempt and need for perineal support and digitations to assist defecation.[3] Abnormalities like recto-rectal intussusception (RRI), rectocele, urogenital prolapse, generalised pelvic floor descent, enterocele, non- relaxing puborectalis or dyssynergic defecation can be found in a patient with ODS[4] The diagnosis of ODS is established by amalgamation of detailed history, careful clinical examination along with radiological (defecography or dynamic magnetic resonance [MR] imaging) and physiological studies (colonic transit time study and anorectal manometry). Initial treatment such as diet modification, pelvic floor exercises and biofeedback improves symptoms in the majority of patients with ODS[2] In selected patients with anatomical abnormalities who fail the trial of conservative treatment, surgical management can be offered.

Several procedures have been mentioned in the literature for the anatomical correction of RRI or rectocele associated with ODS, but long-term results of these surgical procedures are uncertain.[567] Stapled transanal rectal resection (STARR) surgery for ODS which was fairly popularised in the first decade of this century was also not found to be promising on long-term follow-up and symptom improvement after STARR declines with time.[89] Another procedure which gained popularity in Europe in the past decade for the surgical management of ODS is laparoscopic ventral mesh rectopexy (LVMR) with good short-term and limited data on long-term results.[10]

LVMR is a comparatively newer technique which has achieved recognition for the treatment of ODS with limited literature available on its long-term efficacy. This study evaluates the short-term and mid-term results of LVMR for ODS in the Indian population.

SUBJECTS AND METHODS

This study is a retrospective analysis of prospectively collected data from patients who underwent LVMR from January 2015 to January 2017 at a tertiary health-care centre in India. The study was approved by the ethics committee of our institution.

Inclusion criteria

Patients with symptoms suggestive of ODS who have failed to respond to conservative management like exercises, laxatives and three sittings of biofeedback and patients who have structural abnormalities like rectocele (extending 2 cm or more from the rectal wall contour) and/or rectal intussusceptions (>1 cm), as seen on MR defecography, were included in the study.

Exclusion criteria

ODS patients with good response to conservative line of management, patients with secondary constipation and with colonic inertia, patients with full-thickness rectal prolapse and with severe faecal incontinence and patients unfit for general anaesthesia were excluded from the study. In addition, non-consenting patients and patients with follow-up <24 months were excluded from the study.

During the study period, a total of 128 patients were evaluated for constipation of which 36 patients underwent LVMR for ODS. Of the total operated patients, 30 patients fulfilled the criteria and were included in the study.

Pre-operative evaluation

Preliminary evaluation included detailed history of presenting symptoms including the obstetric history and clinical examination. Complete perineal examination including per rectal examination in the left lateral position, lithotomy position and squatting position was performed. Proctoscopy, colonoscopy anorectal manometry and MR defecography were performed for all patients to exclude any associated anorectal diseases. Modified Longo's ODS score [Table 1] was recorded both preoperatively and post surgery to asses response. Details of demographics, presentation, risk factors and surgical details and follow-up were recorded.

Table 1

Modified Longo score for obstructive defecation syndrome

Questions	Scores
Medication to evacuate (enemas or suppositories)	0	1	2	3
Difficulties to evacuate	0	1	2	3
Digitation to evacuate	0	1	2	3
Return to toilet to evacuate	0	1	2	3
Feeling of incomplete evacuation	0	1	2	3
Straining to evacuate	0	1	2	3
Time needed to evacuate	0	1	2	3
Lifestyle alteration	0	1	2	3

Each point is scored according to frequency of the symptom. Questions 1–6 – 0: Never, 1: Less than once weekly, 2: 1–6 times weekly, 3: Every day. Question 7 – 0: Less than 5 min, 1: 6–10 min, 2: 11–20 min, 3: More than 20 min, question 8 – 0: No alteration of lifestyle, 1: Mild alteration, 2: Moderate alteration, 3: Significant alteration of lifestyle. The total score is in the range of 0 (best) to 24

Operative technique

Patients were induced under general anaesthesia and placed in a modified Lloyd-Davies position to allow significant Trendelenburg and lateral tilt position. Per urethral catheter was placed in all the patients. Operating surgeon stands on the right side of the patient. Pneumoperitoneum was created and a 10 mm umbilical port was placed for camera. We preferred a 10-mm 30° telescope. The second port is a 10 mm working port in the mid-clavicular line 5 cm medial to the right anterior superior iliac spine and another 5 mm working port is placed in the line of the first port superiorly just below the level of umbilicus. Two 5 mm retraction ports were placed in the left flank and left of the umbilicus in the mid-clavicular line. In female patients with no previous history of hysterectomy, the uterus was hitched to the anterior abdominal wall using a linen thread. Steep head low is given to the patient and the small bowel is parked in the upper abdomen. The upper rectum is retracted superiorly and laterally to expose the mesorectum and the sacral promontory. An incision was taken over the peritoneum from the sacral promontory and dissection was carried out with a Monopolar Hook down up to levator ani on the right side, this peritoneum incision was extended anteriorly over the rectum and towards the left side to expose the left levator ani. Care was taken to avoid injury to the ureter, gonadal vessels and the hypogastric nerves. Anteriorly, the rectum was mobilised up to the rectovaginal septum in females and beyond the seminal vesicles in males. The lateral ligament was spared. No posterior mobilisation of the rectum was done. This was nerve-sparing dissection which prevents post-operative de novo constipation. The dissection was carried out till the pelvic floor up to the ampulla of the rectum and both the levator ani were exposed. We used a PROLENE® mesh, cut into L shaped (15 cm × 6 cm). The short limb of the L was sutured with both the levator ani laterally and anteriorly to the rectum (seromuscular stitches) with 2-0 Ethibond sutures. The long limb of L was tacked at the sacral promontory with a metal tack. The peritoneum was then closed over the mesh with 2-0 Vicryl and the mesh was extraperitonealised. Thorough wash was given. Haemostasis was checked followed by port closure.

Post-operative follow-up

Patients were started orally after 6 h following surgery and were discharged after 72 h following surgery on bulk forming laxatives for 2 weeks. Patients were followed up on OPD basis at the end of 1 week, 3 weeks, 3 months, 6 months and 12 months. A telephonic interview was carried out at the end of 18 months and 2 years. Modified Longo's ODS scores were assessed at 6 months, 12 months and 24 months. Patients were evaluated for constipation, symptom recurrence, use of laxatives, mesh erosions, urinary or sexual problems. All the data were electronically recorded and then assessed.

Statistical analysis

Descriptive analysis was done and categorical variables were described as frequencies with percentages. Continuous variables were expressed as means with standard deviation. To compare the changes in the mean ODS score over the period of time, Wilcoxon signed-rank test was used.

RESULTS

In the present study, a total of 30 patients (28 females and 2 males) underwent LVMR for ODS due to anatomical abnormality. The mean age of the study group was 52.37 years (range: 37–70 years) [Table 2]. The mean pre-operative modified Longo's ODS score was 23.17 ± 4.82 which decreased to 2.37 ± 1.59 at the end of 6 months and 1.23 ± 1.14 and 1.57 ± 1.14 at the end of 12 months and 2 years, respectively. The mean modified Longo's ODS score showed a significant fall of 94.7% from pre-operative value at 12-month follow-up and 93.2% fall on 2-year follow-up [Table 3 and Figure 1].

Table 2

Demographical data

Parameters
Number of cases	30
Age (years)
Mean	52.37
SD	08.45
Range (years)	37.00-70.00
Sex (%)
Male	2 (6.7)
Female	28 (93.3)

SD: Standard deviation

Table 3

Changes in mean obstructive defecation syndrome score among the study cases

Duration	Mean ODS score (X±SD) (n=30)
Preoperative	23.17±04.82
Postoperative
6 months	02.37±01.59
1 year	01.23±01.14
2 year	01.57±01.14
Mean difference (preoperative - postoperative 6 months)	−20.80±04.27*
Mean difference (preoperative - 1 year)	−21.93±04.54*
Mean difference (preoperative - 2 years)	−21.60±04.86*
Postoperative 6 months, mean ODS score showed a significant fall of 89.8% from preoperative
After 1 year of treatment, mean ODS score showed a significant fall of 94.7% from preoperative
After 2 years of treatment, mean ODS score showed a significant fall of 93.2% from preoperative

By Wilcoxon signed-rank test, *Significant. ODS: Obstructive defecation syndrome

Figure 1

Changes in mean odds score among the study cases

MRI defecography was done for all the patients preoperatively which showed that 50% patients had RRI with rectocele and 36.7% patients had RRI alone. About 13.3% of the patients were found to have rectocele alone [Table 4 and Figure 2].

Table 4

Rectal anatomical abnormality on magnetic resonance defecography

Anatomical abnormality on MRD	Number of cases (n=30), n (%)
Recto rectal intussusception with rectocele	15 (50.0)
Recto rectal intussusception alone	11 (36.7)
Rectocele alone	4 (13.3)

MRD: Magnetic resonance defecography

Figure 2

Rectal anatomical abnormality on magnetic resonance defecography

The mean operative time was 115 min (range: 90 min to 150 min). None of the patients had any major Intraoperative bleeding requiring blood transfusion. All the patients had smooth perioperative and post-operative course. Per urethral catheter was removed on the 1st post-operative day. Majority (73.3%) of the patients were discharged on the 3rd post-operative day on bulk forming laxatives for 2 weeks. The average hospital stay of patients who underwent LVMR was 3.26 days [Table 5 and Figure 3].

Table 5

Profile of post-operative stay among the study cases

Post-operative stay (days)	Number of cases (n=30), n (%)
3	22 (73.3)
4	8 (26.7)
Mean (days)	3.26

Figure 3

Profile of post-operative stay among the study cases

None of the patients required daily use of laxatives at the end of 3 months and had no urinary complaints at the end of 3 months. None of the patients complained of persistent vaginal discharge or dyspareunia. Of the two male patients also, none of them had developed any urinary complaints or sexual complaints. Continence for both flatus and faeces was there in all the patients and was not disturbed postoperatively. In the short- and mid-term follow-up, we did not encounter any mesh-related complication in the post-operative patients. Patients were given a questionnaire at the end of 2-year follow-up to assess their satisfaction with the surgery, with the options being very satisfied, satisfied, poorly satisfied and unsatisfied. About 78% of the patients reported as very satisfied and 13% patients reported that their post-operative outcome as satisfied.

DISCUSSION

Anatomical abnormalities like rectocele or RRI can cause ODS. Surgical correction of the anatomical abnormality may resolve ODS.

Ventral rectopexy, initially described by D'Hoore and Penninckx, involved mobilisation of only the anterior rectum.[11] By minimising the posterior dissection, it reduces the chances of nerve injury, thereby reducing the possibility of development of post-operative de novo constipation.[12] As opposed to resection rectopexy, the sigmoid colon is spared in ventral mesh rectopexy. To eliminate the rectocele or enterocele, the pouch of Douglas is obliterated and a prosthetic mesh is used anteriorly between the rectum and vaginal vault.

LVMR is gaining wider acceptance for treating external and internal rectal prolapse (IRP). It also allows for correction of rectocele, enterocele and vault prolapse while preserving the neuromuscular function of the pelvic floor, the outcome of which is to improve the functional symptoms associated with the prolapse. This surgery is technically demanding and requires a high level of expertise and skill and judgement for patient selection and technique.

A systematic review (SR) of 18 studies (1238 patients) reported outcomes of patients with IRP treated by LVMR and robotic ventral mesh rectopexy (RVMR). The SR reported that anatomic correction of internal rectal prolapsed was achieved in 80% to 100% of patients who had LVMR or RVMR. The same SR reported that solitary rectal ulcer syndrome improved in 75% of patients after LVMR.[13] This SR also reported an improvement in constipation assessed by the Cleveland Clinic Constipation Score from a median of 14 (range: 7–18) preoperatively to a median of 5 (range: 4–7) after LMVR. Another SR of 23 studies and 1460 patients also reported a statistically significantly decrease in constipation in patients with ODS after LVMR (P < 0.0001).[14]

In the current study also, we found that functional results of this surgery are good with a statistically significant decrease in the mean modified Longo's ODS score in the post-operative period assessed at 3 months, 1 year and 2 years post surgery.

The development of de novo sexual dysfunction has been reported in literature following LVMR, but its incidence is extremely low. In the case series of 50 patients who had LVMR for high-grade IRP, 9% of patients reported deterioration of sexual function after LVMR and 64% reported that sexual function improved after LVMR.[15] In a study of 27 patients of LVMR, 1 patient developed post-operative sexual dysfunction.[16] We in our series did not come across any patient developing sexual dysfunction following surgery on a 2-year follow-up.

In the case series of 919 patients who had LVMR for IRP or rectocele with or without enterocele, a 7% rate of anatomical recurrence was reported at a mean follow-up of 24.8 months.[10] In the current study, post-operative imaging was not done; hence, the incidence of anatomic recurrence cannot be assessed, but at the end of 2-year follow-up, the functional results showed significant improvement assessed on the basis of a questionnaire including modified ODS Longo score.

Using a synthetic mesh always imposes a risk of mesh-related complications. In a multicentre collaboration (a study of 2200 patients) to assess the safety of LVMR, it was found that mesh erosion was 2%.[17] These patients subsequently required some or the other surgical procedures like anterior resection or local excision or stoma creation. They found that mesh-related complications were higher with synthetic mesh as compared to biological mesh. In addition, the polyester mesh was associated with a statistically significantly higher risk of mesh erosion as compared to polypropylene and titanium-coated polypropylene meshes. In the current study, we did not encounter any such complication on 2-year follow-up.

For ODS due to rectal anatomical abnormality, STARR had also shown good short-term results, but it showed a declining trend in functional outcome with relation to time.[89] The limitation of this study is that it is not a comparative study between procedures for ODS. Furthermore, there is small sample size and limited follow-up this study. However, this study adds to the existing literature on ventral mesh rectopexy and shows its safety and efficacy in developing country like India. LVMR has shown a good short-term outcome in patients with ODS and has shown acceptability amongst the patients in developing nations. Further studies are required with a larger sample size and a longer follow-up for this procedure to get more recognition amongst masses in the developing world.

CONCLUSION

LVMR is a safe surgical procedure with minimal complications and good short-term functional results for ODS patients due to rectal anatomical abnormality in the developing world. Significant functional improvement can be accomplished in carefully selected patients of ODS undergoing LVMR. Further studies with larger sample size, longer follow-up and comparative studies are still required to decide the best treatment modality for ODS in developing countries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.