Anna R. Spivak

Pelvic floor disorders (PFDs) encompass multiple conditions that affect the proper functioning of pelvic organs. It mostly affects women, however with increased longevity more commonly seen in men. One in three women is affected in a lifetime, 17% of women have more than one symptom ranging from incontinence, obstructive defecation, fistula, or pelvic organ prolapse. The prevalence increases with age and nearly half of women over the age of 80 are affected by a pelvic floor condition. These diseases are benign, however, they can be debilitating and have a tremendous effect on patients' quality of life. The symptoms take years to develop and there is rarely a “simple” treatment solution. It is a well-established fact that multidisciplinary collaboration is needed when treating patients with disorders of the pelvic floor. In this edition of Clinics in Colon and Rectal Surgery, a group of pelvic floor experts brings together 10 articles that discuss different aspects of the diagnosis and treatment of PFD. The first documented rectal prolapse dates back to 1500 BC, the history of the rectal prolapse article will take you through time and different management strategies that were utilized. Unfortunately, one theme remains the same, the etiology of rectal prolapse is poorly understood and there is still no perfect treatment procedure. The only change in the 21st century is our understanding that rectal prolapse, like all disorders of the pelvic floor, is not an isolated diagnosis of just one organ and requires a multidisciplinary approach to treatment. In our practice, we collaborate closely with physiotherapists, behavioral gastrointestinal psychology, urogynecology/urology, gastroenterology, and other subspecialties. In this edition, I invited our colleagues to share their perspectives on diagnosis and treatment and discuss the strategies each specialty uses to treat PFD. Pelvic floor physiotherapists (PFPTs) are our closest collaborators. Oftentimes, the only role of the colorectal surgeon is to make a diagnosis and PFPT takes over treatment. PFPT is not one-size-fits-all and treatment strategies utilized by a therapist vary with each patient and diagnosis, the article by the physiotherapist describes such techniques and the role of PFPT. Psychology is another close collaborator who is an incredibly valuable resource. Many of the patients with PFD have coexisting anxiety, depression, eating disorders, chronic pain syndromes, and posttraumatic stress disorders. The article by a group of psychologists who specialize in brain–gut connection and pelvic pain provides their perspective and treatment options for PFD patients. PFD symptoms can be difficult to quantify and characterize as they vary and can overlap, an excellent description of current tools is summarized for the reader by Dr. Liliana Bordeianou. Recurrent prolapse, low anterior resection syndrome, multicompartment prolapse, and fistula to neovagina are unique challenges for the pelvic floor surgeon. Experts in the field are sharing their knowledge in managing these diagnoses in their articles. Pelvic floor patients oftentimes do not need surgery but do require longitudinal follow-up past the diagnosis and close collaboration with advance practice provider (APP) is an essential part of a successful pelvic floor practice. Lieba Savitt, CNP, describes Massachusetts General Hospitals (MGH's) journey to building pelvic floor practice, a collaborative treatment model of APP and colorectal surgeons to provide safe patient care and improve patient outcomes and satisfaction. Diagnosis and treatment of PFDs are complex and start with listening to the patient and taking a deep dive into the medical records. Dr. Tracy Hull shares her reflection on 30 years of taking care of patients with PFDs. Treatment of patients with PFDs requires a thoughtful collaboration between multiple specialties, we are fortunate to have a group of like-minded providers at the Cleveland Clinic, and we discuss complex patients at our weekly conference where every subspecialty has an opportunity to weigh in on a comprehensive collaborative treatment plan. When compiling this edition, I aimed to bring different experts' views and opinions to the reader to highlight the importance of addressing variable aspects of the PFD, as well as resources that can help with the treatment of this challenging diagnosis. I hope that you will find this pelvic floor edition of Clinics in Colon and Rectal Surgery educational and interesting. Article published online: 20 February 2025 © 2025. Thieme. All rights reserved. Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

Introduction Patients with multiple sclerosis and Parkinson’s disease may experience pelvic floor dysfunction and constipation which can affect ileoanal pouch emptying. This can lead to complications such as pouchitis, pouch dysfunction, and failure. We hypothesized that patients with neurological diseases have a higher rate of pouch failure and complications than healthy controls. Methods Data were sourced from the institutional ileoanal pouch database. Patients with multiple sclerosis or Parkinson’s disease, diagnosed before or after pouch construction, were matched to a control group of patients without neurological disease using propensity score-optimal matching. Demographics, postoperative and functional outcomes, and quality of life were analyzed. Results Twenty-six patients (38%) with multiple sclerosis and 16 (62%) with Parkinson’s disease were matched with 42 healthy controls. The overall median age was 39 years, median BMI was 25.3 kg/m², and most patients were female (61.9%). Preoperative colorectal diagnoses included ulcerative colitis (83.3%), indeterminate colitis (9.5%), and Crohn’s disease (7.1%). Patients with neurological diseases had higher ASA scores (class III, 57.1% vs. 21.4%; p < 0.01), fewer nocturnal bowel movements (median 0 vs. 2; p < 0.001), fewer bowel movements over 24 h (median 6 vs. 8; p = 0.01), and were less likely to recommend IPAA construction (72.7% vs. 97%; p = 0.01) than the controls. Other surgical, functional, and quality-of-life outcomes were similar. Conclusion Patients with multiple sclerosis or Parkinson’s disease might differ in pouch function compared with healthy controls. These neurological diseases might affect pouch function. The rate of pouch failure was similar, showing its feasibility despite multiple sclerosis and Parkinson’s disease.

BACKGROUND: Resection rectopexy and ventral mesh rectopexy are widely accepted surgical options for the treatment of rectal prolapse; however, reports on long-term recurrence rates and functional outcomes are lacking. OBJECTIVE: We compared quality of life, long-term functional outcomes, and prolapse recurrence after resection rectopexy versus ventral mesh rectopexy. DESIGN: We retrospectively reviewed our prospectively collected rectal prolapse surgery database. SETTINGS: Patients who underwent resection rectopexy or ventral mesh rectopexy at our center between 2009 and 2016 were included. PATIENTS: Two hundred twenty patients were included, of whom 208 (94%) were women; 85 (39%) underwent resection rectopexy and 135 (61%) ventral mesh rectopexy. MAIN OUTCOME MEASURES: Prolapse recurrence. RESULTS: The resection rectopexy group was younger (median 52 vs 60 years old, p = 0.02) and had more open procedures (20% vs 9%, p < 0.001). After a median follow-up of 110 (interquartile range 94–146) months for resection rectopexy and 113 (87–137) months for ventral mesh rectopexy, recurrences occurred in 21 (26%) in the resection rectopexy and 50 (39%) in the ventral mesh rectopexy group (p = 0.041). The median time to recurrence was 44 (18–80) months in the resection rectopexy group and 28.5 (11–52.5) months in the ventral mesh rectopexy group (p = 0.14). There were no differences in the recurrence rate for primary prolapses in resection rectopexy versus ventral mesh rectopexy. The recurrence rate for redo prolapses was higher in the ventral mesh rectopexy group at 63% at 10 years versus 25% in the resection rectopexy group (p = 0.006). Functional outcomes were similar between the 2 groups. LIMITATIONS: Retrospective review, recall bias. CONCLUSIONS: Long-term quality of life and functional outcomes after resection rectopexy and ventral mesh rectopexy were comparable. Ventral mesh rectopexy was associated with a higher prolapse recurrence rate after recurrent rectal prolapse repair. See Video Abstract. CALIDAD DE VIDA, RESULTADOS FUNCIONALES Y RECURRENCIA DESPUÉS DE LA RECTOPEXIA POR RESECCIÓN VERSUS LA RECTOPEXIA VENTRAL CON MALLA PARA LA REPARACIÓN DEL PROLAPSO RECTAL: ANTECEDENTES: La rectopexia de resección y la rectopexia ventral con malla son opciones quirúrgicas ampliamente aceptadas para el tratamiento del prolapso rectal; sin embargo, faltan informes sobre las tasas de recurrencia a largo plazo y los resultados funcionales. OBJETIVO: Comparamos la calidad de vida, los resultados funcionales a largo plazo y la recurrencia del prolapso después de la rectopexia de resección versus la rectopexia ventral con malla. DISEÑO: Revisamos retrospectivamente nuestra base de datos de cirugía de prolapso rectal recopilada prospectivamente. ENTORNO CLÍNICO: Se incluyeron pacientes sometidos a rectopexia resección o rectopexia ventral con malla en nuestro centro entre 2009 y 2016. PACIENTES: Se incluyeron 220 pacientes, de los cuales 208 (94%) eran mujeres; 85 (39%) fueron sometidos a rectopexia de resección, 135 (61%) rectopexia ventral con malla. INTERVENCIONES: Ninguna. PRINCIPALES MEDIDAS DE VALORACIÓN: Recurrencia del prolapso. RESULTADOS: El grupo de rectopexia de resección era más joven (mediana 52 vs 60 años, p = 0,02) y tenía más procedimientos abiertos (20% vs 9%, p < 0,001). Después de una mediana de seguimiento de 110 (RIC 94 – 146) meses para la rectopexia de resección y 113 (87 – 137) para la rectopexia ventral con malla, se produjeron recurrencias en 21 (26%) del grupo de rectopexia de resección y en 50 (39%) del grupo de rectopexia ventral con malla (p = 0,041). La mediana del tiempo hasta la recurrencia fue de 44 (18 – 80) meses en el grupo de rectopexia de resección y 28,5 (11 – 52,5) en el grupo de rectopexia ventral con malla (p = 0,14). No hubo diferencias en la tasa de recurrencia de prolapsos primarios en la rectopexia de resección versus la rectopexia con malla ventral. La tasa de recurrencia de prolapsos repetidos fue mayor en el grupo de rectopexia con malla ventral, 63% a los 10 años, versus 25% en el grupo de rectopexia con resección (p = 0,006). Los resultados funcionales fueron similares entre los dos grupos. LIMITACIONES: Revisión retrospectiva, sesgo. CONCLUSIÓN: La calidad de vida a largo plazo y los resultados funcionales después de la rectopexia de resección y la rectopexia ventral con malla fueron comparables. La rectopexia ventral con malla se asoció con una mayor tasa de recurrencia del prolapso después de la reparación del prolapso rectal recurrente. (Traducción—Ingrid Melo)

Background: A colosplenic fistula (CsF) is an extremely rare complication. Its diagnosis and management remain poorly understood, owing to its infrequent incidence. Our objective was to systematically review the etiology, clinical features, diagnosis, management, and prognosis to help clinicians gain a better understanding of this unusual complication and provide aid if it is to be encountered. Methods: A systematic review of studies reporting CsF diagnosis in Ovid MEDLINE, Ovid EMBASE, Scopus, Web of Science, and Wiley Cochrane Library from 1946 to June 2022. Additionally, a retrospective review of four cases at our institution were included. Cases were evaluated for patient characteristics (age, sex, and comorbidities), CsF characteristics including causes, symptoms at presentation, diagnosis approach, management approach, pathology findings, intraoperative complications, postoperative complications, 30-day mortality, and prognosis were collected. Results: Thirty patients with CsFs were analyzed, including four cases at our institution and 26 single-case reports. Most of the patients were male (70%), with a median age of 56 years. The most common etiologies were colonic lymphoma (30%) and colorectal carcinoma (17%). Computed tomography (CT) was commonly used for diagnosis (90%). Approximately 87% of patients underwent a surgical intervention, most commonly segmental resection (81%) of the affected colon and splenectomy (77%). Nineteen patients were initially managed surgically, and 12 patients were initially managed nonoperatively. However, 11 of the nonoperative patients ultimately required surgery due to unresolved symptoms. The rate of postoperative complications was (17%). Symptoms resolved with surgical intervention in 25 (83%) patients. Only one patient (3%) had had postoperative mortality. Conclusions: Our review of 30 cases worldwide is the largest in literature. CsFs are predominantly complications of neoplastic processes. CsF may be successfully and safely treated with splenectomy and resection of the affected colon, with a low rate of postoperative complications.

Purpose: Recurrence of rectal prolapse following the Altemeier procedure is reported with rates up to 40%. The optimal surgical management of recurrences has limited data available. Ventral mesh rectopexy (VMR) is a favored procedure for primary rectal prolapse, but its role in managing recurrences after Altemeier is unclear. VMR for recurrent prolapse involves implanting the mesh on the colon, which has a thinner wall, more active peristalsis, no mesorectum, less peritoneum available for covering the mesh, and potential diverticula. These factors can affect mesh-related complications such as erosion, migration, or infection. This study assessed the feasibility and perioperative outcomes of VMR for recurrent rectal prolapse after the Altemeier procedure. Methods: We queried our prospectively maintained database between 01/01/2008 and 06/30/2022 for patients who had experienced a recurrence of full-thickness rectal prolapse following Altemeier’s perineal proctosigmoidectomy and subsequently underwent ventral mesh rectopexy. Results: Ten women with a median age of 67 years (range 61) and a median BMI of 27.8 kg/m² (range 9) were included. Five (50%) had only one Altemeier, and five (50%) had multiple rectal prolapse surgeries, including Altemeier before VMR. No mesh-related complications occurred during a 65-month (range 165) median follow-up period. Three patients (30%) experienced minor postoperative complications unrelated to the mesh. Long-term complications were chronic abdominal pain and incisional hernia in one patient, respectively. One out of five (20%) patients with only one previous prolapse repair had a recurrence, while all patients (100%) with multiple prior repairs recurred. Conclusion: Mesh implantation on the colon is possible without adverse reactions. However, high recurrence rates in patients with multiple previous surgeries raise doubts about using VMR for secondary or tertiary recurrences.