Anthony R. Dixon

Laparoscopic ventral mesh rectopexy (LVMR) is an established treatment for external full-thickness rectal prolapse. However, its clinical efficacy in patients with internal prolapse is uncertain due to the lack of high-quality evidence. An individual level, stepped-wedge randomised trial has been designed to allow observer-blinded data comparisons between patients awaiting LVMR with those who have undergone surgery. Adults with symptomatic internal rectal prolapse, unresponsive to prior conservative management, will be eligible to participate. They will be randomised to three arms with different delays before surgery (0, 12 and 24 weeks). Efficacy outcome data will be collected at equally stepped time points (12, 24, 36 and 48 weeks). The primary objective is to determine clinical efficacy of LVMR compared to controls with reduction in the Patient Assessment of Constipation Quality of Life (PAC-QOL) at 24 weeks serving as the primary outcome. Secondary objectives are to determine: (1) the clinical effectiveness of LVMR to 48 weeks to a maximum of 72 weeks; (2) pre-operative determinants of outcome; (3) relevant health economics for LVMR; (4) qualitative evaluation of patient and health professional experience of LVMR and (5) 30-day morbidity and mortality rates. An individual-level, stepped-wedge, randomised trial serves the purpose of providing an untreated comparison for the active treatment group, while at the same time allowing the waiting-listed participants an opportunity to obtain the intervention at a later date. In keeping with the basic ethical tenets of this design, the average waiting time for LVMR (12 weeks) will be shorter than that for routine services (24 weeks). ISRCTN registry, ISRCTN11747152 . Registered on 30 September 2015. The trial was prospectively registered (first patient enrolled on 21 March 2016).

WITHDRAWAL: A. Newman, G.L. Greenslade, K. McCarthy, and A.R. Dixon, “Outcomes for Patients with Apparent Chronic Idiopathic Pelvic Pain and Associated Pelvic Floor Disorders Undergoing Laparoscopic Ventral Mesh Rectopexy,” Colorectal Disease (Accepted Article). https://doi.org/10.1111/codi.13805.The above article, published online on 6 July 2017 in Wiley Online Library (wileyonlinelibrary.com), has been withdrawn by agreement between the journal Editors‐in‐Chief, Sue Clark and Neil Smart; The Association of Coloproctology of Great Britain and Ireland; and John Wiley & Sons Ltd. The withdrawal has been agreed due to concerns raised regarding the legitimacy of the data reported and allegations of a lack of informed consent from patients who underwent the surgical procedure reported within.

Aim: Laparoscopic ventral mesh rectopexy (LVMR) has been used to treat rectal prolapse, obstructed defaecation (OD), faecal incontinence (FI) and multicompartment pelvic floor dysfunction. Its value in treating men has been questioned. The aim of the present study was to assess the results in male patients.Method: A password‐protected electronic database of all LVMRs carried out in North Bristol NHS trust & Spire hospital between 2002 and 2013 was examined. In addition to the clinical outcome, quality of life (QoL), Cleveland Clinic Incontinence Score (CCIS), obstructed defecation syndrome (ODS) score, visual analogue score (VAS) for the severity of bowel and urinary symptoms and the numerical rating scale (NRS) for pain and patient‐reported outcome measures were evaluated.Results: Sixty‐eight men of median age 35 years and body mass index 26 kg/m² underwent LVMR for external rectal prolapse (18) or Grade III–V rectal intussusception (50) presenting with OD, FI and pelvic pain. Ten per cent had been labelled ‘chronic idiopathic pelvic pain’ and 60% had undergone previous haemorrhoidal surgery. Complications were minor and included urinary retention (10%). Eighty per cent of patients had an uncomplicated recovery with 24% being treated as day cases. There were no cases of impotence or retrograde ejaculation. Median follow‐up was 42 (IQR 26–61) months. CCIS score improved from 4 (IQR 0–8) to 0 (IQR 0–0) (P < 0.001) and the ODS score from 18.5 (IQR 16–22) to 6 (IQR 5–8) (P < 0.001). Patients reported significant improvement in the NRS for pain and QoL (BBSQ‐22) at 3 months (P = 0.000). The QoL and the VAS for bowel symptoms were maintained at 4 years. At the last follow‐up 56 (82%) patients were asymptomatic and 6 (8.8%) had persisting symptoms. There was no case of recurrent external rectal prolapse.Conclusion: LVMR is an effective treatment for external and symptomatic internal rectal prolapse in men, leading to significant improvement in QoL and function.

Aim: Laparoscopic ventral mesh rectopexy (LVMR) is increasingly recognized as having utility in rectal prolapse, obstructive defaecation syndrome (ODS), faecal incontinence (FI) and multicompartment pelvic floor dysfunction (PFD). This study aimed to highlight gaps in service provision and areas for improvement by examining a cohort of patients with complications referred to a tertiary centre.Method: Examination was carried out of a password‐protected electronic database of all LVMRs operated on in one institution.Results: Fifty patients (45 women), median age 54 (range, 24–71) years, were referred with early symptomatic failure (n = 27) following an inadequate LVMR or major mesh complications (erosion into another organ, fistulation or stricturing) (n = 23). All were amenable to remedial laparoscopic surgery. Functional improvements were found in pre‐ and postoperative ODS, Wexner (FI) scores (two‐tailed t‐test; P < 0.0001) and quality of life (Birmingham Bowel and Urinary Symptoms Questionnaire‐22) scores at 3 months (two‐tailed t‐test; P < 0.001) and normalization at 1 year (P < 0.015). This was mirrored by improved linear bowel symptom severity visual analogue scale scores (two‐tailed t‐test; P < 0.0001 at 3 months and P = 0.015 at 1 year) .Conclusion: LVMR can be associated with technical complications arising from inadequate technique or from operation‐specific complications that are amenable to complex revisional laparoscopic surgery with significant improvement in quality of life and function.

Aim: The treatment of solitary rectal ulcer syndrome (SRUS) is notoriously difficult. Laparoscopic ventral mesh rectopexy (LVMR) is a nonresectional technique for patients with full thickness external rectal prolapse and internal prolapse with obstructed defaecation syndrome (ODS), features associated in the pathogenesis of SRUS. Our aim was to assess the short‐ and long‐term efficacy of LVMR in treating SRUS.Method: Forty‐eight patients with SRUS who underwent LVMR over a 15‐year period (December 1996 to July 2012) were identified from a prospectively maintained electronic database.Results: Forty‐eight patients, 38 (79%) women, median age 43 (18–80) years, median body mass index 26 (21–40) kg/m² underwent LVMR for SRUS after initial biofeedback. The median follow‐up was 33 months (95% CI 31–55, range 1–186 months); 52% were followed for more than 3 years and 13 (27%) for more than 5 years. Five (10%) had relapsed following a response to stapled transanal rectal resection (STARR; 10 additional patients have had a continued response to STARR). Eleven (23%) had intermittent reducible external prolapse. Epithelial ulcer healing was reported in all patients at 3 months. The ODS scores improved by 68% (P < 0.0001) and quality of life (QoL; Birmingham Bowel and Urinary Symptoms Questionnaire‐22) scores improved by 45% (P < 0.0001). There was a significant improvement in bowel visual analogue scale (VAS) scores at 3 and 12 months (P = 0.0007). Sustained improvement in QoL and VAS scores was maintained at 2 years and continued in the 52% followed up for between 3 and 15 years. There were four (8%) symptomatic ODS recurrences: posterior rectal wall prolapse successfully treated by STARR (3) and one symptom free for 2 years following a temporary loop ileostomy. There were two recurrences (4%).Conclusion: LVMR appears to provide a sustained improvement in QoL, VAS and patient satisfaction in patients with SRUS. Morbidity, recurrence and safety profiles are low.

Aims  Enhanced recovery programmes after colorectal surgery are promoted to minimize complications and expedite recovery, thus reducing length of hospital stay where appropriate and improving the overall standard of patient care. There are few published trials of enhanced recovery programmes in the context of laparoscopic colorectal surgery.Methods  Data were prospectively collected on all laparoscopic colorectal resections carried out in our institution from May 2004 to November 2009. An informal move to 48‐h discharge was introduced in May 2004 and the official enhanced recovery programme was launched in November 2008. We identified all patients with a primary anastomosis discharged within 3 days of surgery. Early outcomes – leaks, complications, readmission rates and returns to theatre – were analysed.Results  In all, 606 resections were performed in this period. Median length of stay was 4 (0–52) days. Of these patients, 279 (46%) met the criteria of accelerated discharge by day 3: 2 (0.7%) were discharged on the day of surgery, 70 (25.1%) within 24 h, 116 (41.6%) within 48 h and 91 (32.6%) by 72 h. Age was not a significant factor in determining length of stay. Patients undergoing right hemicolectomy were more likely to be discharged by 24 h than those with left‐sided anastomoses, and patients having total mesorectal excision resections were more likely to stay 3 days. The readmission rate was 4%, regardless of day of discharge.Conclusion  Accelerated discharge is feasible and safe. High readmission rates reported in enhanced recovery programmes after open colorectal surgery have not occurred in our laparoscopic experience.

Aim  Single‐incision laparoscopic surgery (SILS) is gaining momentum. The aim of the present study was to compare the outcome of SILS for high anterior resection with that of standard laparoscopic resection (StdLS).Method  Patients undergoing laparoscopic high anterior resection were prospectively entered into an institutional approved database. Patients treated with SILS were compared with those undergoing StdLS.Results  Between April 2000 and April 2009, 327 (143 cancer) consecutive unselected patients underwent StdLS; there were three (1%) conversions and 12 (3.6%) covering ileostomies. After April 2009, 55 (29 cancer) consecutive, unselected patients underwent SILS; there were two conversions to a three‐port technique (3.6%), no conversions to open resection and two (3.6%) covering ileostomies. There were no significant differences in age, sex, body mass index, hospital of operation or American Society of Anesthesiology (ASA) grade between the two groups. The operating time for SILS was significantly shorter (113 ± 44 min for StdLS vs 79 ± 37 min for SILS; P < 0.0001). SILS patients tolerated a normal diet earlier [10 (2–24) h for SILS vs 18 (2–96) h for StdLS] and were discharged faster [1 (1–8) days for SILS vs 3 (1–24) days for StdLS]. There were no significant differences in return to theatre, readmissions or 30‐day mortality.Conclusion  SILS for high anterior resection is feasible, safe and quicker to perform than standard three‐port laparoscopic colectomy. It seems to be associated with a faster recovery and earlier discharge.