Rectal Prolapse: What Is the Best Approach for Repair?
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 ofte
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Rectal Prolapse: What Is the Best Approach for Repair? Saleh Eftaiha and Anders Mellgren
Introduction 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]. However, solely using a framework of abdominal vs. perineal approach infers an oversimplification of the principles and choices for the surgical correction of rectal prolapse. As we consider the available approaches, we inevitably encounter different operations associated with each approach: suture posterior rectopexy, with or without resection, vs. ventral rectopexy and the Altemeier procedure vs. the Delorme procedure. There is a paucity of high quality evidence regarding the optimal surgery for the treatment of rectal prolapse [3]. In our examination of the literature, we have included findings of two Cochrane reviews (2000 and 2008), two additional systematic reviews, two nonrandomized control trials (NRCT), seven randomized control trials (RCT), and a number of retrospective reviews. The PROSPER trial, a multicenter RCT primarily based in the United Kingdom, represents the largest and most ambitious exploration in the choice of procedure for rectal prolapse. It included a power analysis and revealed a method of randomization. This trial, however, did not explicitly state whether the assessors were blinded
S. Eftaiha, MD • A. Mellgren, MD, PhD (*) Division of Colon & Rectal Surgery, University of Illinois Chicago, Chicago, IL, USA e-mail: [email protected] © Springer International Publishing Switzerland 2017 N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery, Difficult Decisions in Surgery: An Evidence-Based Approach, DOI 10.1007/978-3-319-40223-9_31
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and the trial was underpowered. The majority of the other reported RCT’s were performed in a single center, often did not carry out a power analysis, usually included less than 50 patients, and frequently did not state method of randomization. One of them was limited to 6 months of follow-up [27]. With these methodological weaknesses in mind, the present assessment aimed to evaluate different types of rectal prolapse repair and review different types of outcomes including recurrence rates, function, quality of life and morbidity.
Search Strategy The following broad PICO terms were used: patients with rectal prolapse, abdominal approach, and perineal approach, outcomes including recurrence of prolapse, functionality, quality of life, morbidity and mortality (Tabl
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