Clinical Outcome after Resection Rectopexy in patients with Constipation and Rectal Prolapse

Purpose Laparoscopic resection rectopexy (LRR) is an established procedure for the treatment of rectal prolapse. This study evaluated constipation and gastrointestinal quality of life in patients before and after LRR for rectal prolapse. Methods 30 patients (24 females, 6 males) underwent laparoscopic anterior (n = 14), posterior (n = 8) and suture resection rectopexy (n = 8) for rectal prolapse during 2010–2020. 25 were retrospectively evaluated for constipation and gastrointestinal quality of life using validated Cleveland Clinic Constipation Score (CCCS) and Gastrointestinal Quality of Life Index (GIQLI).


Introduction
Rectal prolapse, or procidentia, is de ned as an intussusception of the rectum and can be categorized as occult (internal), mucosal (partial), or complete (external). While internal rectal prolapse does not extend beyond the anus, external prolapse presents as a protrusion of all the rectal wall through the anal canal.
Occult prolapse is seen as a precursor of complete prolapse by some experts. Mucosal prolapse refers to protrusion of only rectal or anal mucosa and should be distinguished from full-thickness prolapse [1].
Factors that increase the risk of rectal prolapse are an age over 40 years, female gender, multiparity, vaginal delivery, prior pelvic surgery, chronic constipation, dementia, pelvic oor dysfunction and anatomic defects (e.g. cystocele, rectocele, enterocele, deep cul-de-sac). This includes the presence of an abnormally deep Douglas, atonic pelvic oor muscles and weakness of the internal and external sphincter. A condition which is often seen in rectum prolapse is a lack of normal xation of the rectum, with a mobile mesorectum and lax lateral ligaments. Due to this condition, the small intestine, which normally lies against the anterior rectal wall, can force the rectum through the anal canal. The female gender is more commonly affected with a peak incidence after the fth decade. Rectal prolapse results in impaired rectal adaptation to distension and most patients present with abdominal discomfort, incomplete bowel evacuation, anal incontinence or constipation leading to obstructive defecation syndrome (ODS) [2,3].
Chronic constipation is a very common and extremely distressing condition for patients, which often signi cantly affects the quality of life. A 2011 meta-analysis of 261,040 patients found a prevalence of 14.0% of chronic constipation in the population [4]. In most cases, abnormal morphology of the pelvis, pelvic oor, colon, or rectum underlies ODS. These anatomic changes often occur in combination and subsequently lead to incomplete or prolonged emptying of the rectal ampulla [5]. Furthermore, symptoms such as increased effort during defecation, need for digital evacuation, and the frequent need for enemas and suppositories are reported. In addition to a detailed medical history, a careful clinical examination is indispensable for the diagnosis of chronic constipation. Rectal prolapse is diagnosed based on the observation of rectal protrusion or defecography. Depending on the results of the examination, further invasive or imaging procedures may be necessary. For the surgical treatment of rectal prolapse causing ODS, various procedures are available, whereby perianal, transvaginal, and transanal can be distinguished from transabdominal procedures [6]. The latter can be categorized into procedures with or without resection of the colon, with or without rectopexy, and with or without the use of allogeneic material. In the case of rectopexy, it is also possible to distinguish ventral from dorsal rectopexy.
Resection rectopexy combines a sigmoid resection with a rectopexy. There is evidence that LRR is superior to mesh rectopexy regarding improvement in obstructed defecation symptoms. Hany et al. could demonstrate an improvement in constipation in 85.6% after LRR compared to 71.4% after ventral mesh rectopexy [7]. The xation of the rectum is done either with sutures or using a mesh. Resection induces the development of a brosis area around the anastomosis and the sacrum. This leads to additional rectal xation to the sacrum and a straighter line for the colon, which avoids torsion and sigmoidocele.
Patients with an elongated sigmoid colon and a slow-transit constipation are especially likely to bene t from this procedure [8]. Although there are already some studies on the functional outcome after surgery for ODS, their use for clinical practice is limited by a large heterogeneity of the studies [9]. Data on LRR for ODS are very limited and the available perioperative data are largely based on small case series.
Therefore, this analysis takes the opportunity to evaluate the postoperative outcome after laparoscopic resection rectopexy in our own patient population. Special focus was set on those patients experiencing constipation as the primary concern. 30 consecutive patients with constipation were operated due to rectal prolapse between January 2010 and December 2020 at the Clinic for General and Visceral Surgery at the Kepler University Hospital Linz. 14 by laparoscopic anterior resection rectopexy (LARR), 8 by laparoscopic posterior resection rectopexy (LPRR) and 8 by laparoscopic suture resection rectopexy (LSRR). 23 of them were suffering from external and 7 from internal rectal prolapse. 6 patients also reported symptoms of fecal incontinence. Concomitant ndings by defecography were rectocele in four patients, enterocele in two patients and an elongated sigmoid colon in ve patients. Additionally, six patients were suffering from diverticular disease. Retrospectively, the clinical and demographic data of the study participants were taken from the hospital information system and all patients were contacted again by telephone. 25 of them were reached and validated Cleveland Clinic Constipation Score (CCCS) and Gastrointestinal Quality of life score (GIQLI) were used to ask them about their preoperative condition and postoperative outcome after resection rectopexy. The GIQLI was divided into ve subgroups including gastrointestinal symptoms, emotions, physical status, social dysfunction and effects of medical treatment. Furthermore, patients were asked about prior surgeries in the abdominal and pelvic area and females about vaginal deliveries. Exclusion criteria for admission to the study were other indications for surgery than constipation and an incomplete follow-up protocol. The study was conducted after approval from the ethics committee and Institutional Review Board.
All patients were evaluated preoperatively by thorough medical history, physical examination, colonoscopy and radiological assessment (defecography, CT scan with gastrogra n preparation and colonic transit time). A detailed assessment was performed of their general condition, comorbidities and risk factors. Gynecologists, urologists, radiologists and pelvic oor physical therapists were also included in discussions as needed.

Variables
All variables were analysed at baseline (preoperative values) and included gender, age, BMI, ASA class, type of surgery, operative time, complications and length of stay. Complications were de ned as minor in cases where no surgical reintervention was necessary (Clavien Dindo grade 1 or 2) and as major when patients had to undergo surgical reexploration (Clavien Dindo grade 3 or higher). Operation time was de ned as the beginning of the skin incision to completion of the surgical dressing. CCCS and GIQLI were used to evaluate constipation and quality of life. The responses-scored using a numerical rating scale were documented before surgery, and at time of the phone survey. The period for recording perioperative results started at the time of surgery and ended with the discharge of the patient. Candidates were evaluated median 68.0 ± 42.8 months after surgery during a phone interview which included lling out the standardised questionnaires. All data concerning the operations and changes resulting from it were reported. Informed consent was obtained from all of the patients.

Statistical analysis
Statistical analysis was performed using the open-source R statistical software package, version 3.6.1 (The R Foundation for Statistical Computing, Vienna, Austria). The type I error was not adjusted for multiple testing. Therefore, the results of inferential statistics are descriptive only. An intention to treat approach as well as a per-protocol approach has been taken. All data of continuous variables were checked for normal distribution (test of normality: Kolmogorov-Smirnov with Lilliefors signi cance correction, type I error = 10%) and for heteroscedasticity (Levene test, type I error = 5%). Comparisons (LARR vs. LPRR vs. LNRRP) of variables with normally distributed data without different variances were performed by a parametric analysis of variance (ANOVA; due to the results, there was no need for multiple comparisons). For comparisons of all other continuous variables and of variables measured on ordinal scales a non-parametric analysis of variance (Kruskal Wallis test, followed by Nemenyi's multiple comparisons) was used. Data of categorical variables were compared by the exact chi-square test (with provision of adjusted residuals). Pre-post-comparisons of continuous variables with normally distributed data were performed by the paired t-test; otherwise and for comparisons of variables measured on ordinal scales the exact Wilcoxon test was used. Multiple regression analyses (including stepwise approaches) were used to investigate the in uence of the following variables on improvement of CCCR and on improvement of GIQLI: type of resection rectopexy, age, BMI, follow up, CCCR, GIQLI, ASA, gender and preoperations.

Operation techniques
In all patients standardized operation techniques were used and all procedures were performed laparoscopically in Lloyd-Davies position under general anesthesia by the same surgical team. All patients had preoperative mechanical bowel preparation and oral antibiotics, as well as perioperative parenteral antibiotics. Pneumoperitoneum was created via the umbilical port (11 mm), with peritoneal insu ation with CO2 gas to the pressure of 12 mm Hg. After insertion of the laparoscope (Storz, Germany), three additional ports were placed under direct vision-one in the right lumbar (11 mm) and right iliac region (11 mm), and one suprapubic (5mm). After exploration of the abdomen and pelvic area dissection was started in the area of the promontory after releasing adhesions to the sigmoid rectum and towards the uterus. The peritoneum was incised, and the superior rectal artery exposed. The left ureter was visualized, then the mesorectal sheath was opened with electrosurgical scissors, the left and right hypogastric plexus were visualized and spared. Dissection corresponding to a TME up to the pelvic oor was performed, whereby heat was not applied to the nerve bundles and only the scissors were used for cutting. The peritoneum was opened at the fold and the rectum was mobilized up to the pelvic oor. Subsequently, a window was created at the upper edge of the superior rectal artery. Mesosigmoideum was dissected in the area of the expected resection border up to the colon with the LigaSure Atlas™ (Medtronic, USA) and then the intestine was skeletonized tubularly up to the lower distal resection border in the transition to the upper middle third of the rectum. Finally, the intestine was set down in one stroke by a linear stapler (iDrive®, Medtronic, USA). Pfannenstiel incision was performed and Alexis® wound protector/retractor was inserted and the measured colon resected. The colorectal anastomosis was performed using a circular stapler (Touchstone, 29 mm; Dach Medical Group, Bürmoos, Austria). A pneumatic test was performed to verify the absence of any primary leakage.
For LARRP a folded TiO2 Mesh™ (10x15cm, MFP111, AFS medical, Austria) was inserted and placed on the anterior wall of the rectum down to the pelvic oor and xed with 0-Prolene® (Ethicon; Somerville, NJ, USA) simple interrupted stitches at a distance of 2 cm from the anterior wall. The upper end is pulled in the direction of the promontory and sutured here directly to the promontory with two simple interrupted stitches. This technique was rst described by D`Hoore in 2004 in order to allow preservation of the autonomic nerves by mobilizing the rectum in the anterior plan only [10].
LPRPP was performed by cutting a TiMESH® in the shape of a cross with the two transverse legs approximately 3 cm long and 2 cm wide. The mesh is held in the correct position on the os sacrum by ProTack™ Fixation Device. The rectum was xed with 0-Prolene® (Ethicon; Somerville, NJ, USA) simple interrupted stitches below the anastomosis on the left and right side of the mesh wings.
For LSRR a continuous suture was made to each side between the peritoneum or lateral os sacrum and the rectum using V-Loc suture without compromising the vascular perfusion, so that the entire intestine is nicely stretched but the anastomosis was naturally free of tension.
Patient demographics and clinical characteristics are shown in Table 1. There was no conversion from laparoscopic to open resection rectopexy. Patients' overall health was graded preoperatively by an anaesthesiologist. 11 patients were assigned to ASA class I and II each and 3 patients were assigned to ASA class III. 19 patients were diagnosed with external and 6 with internal rectal prolapse. Additionally, 4 patients were suffering from diverticular disease and 6 also reported symptoms of anal incontinence.
The overall rate of major complications was 4.0% (n=1). One anastomotic leakage with peritonitis was reported after LSRR and treated with protective loop ileostomy. The overall rate of minor complications was 12.0% (n=3) and included one pelvic abscess after LSRR which was treated with CT-guided drainage and an anastomotic stenosis after LPRR which was treated with endoscopic dilation. One patient developed a paralytic ileus following pneumonia after LSRR and was transferred to the intensive care unit (ICU). All patients recovered well after the treatment.

Discussion
Rectal prolapse is an extremely distressing and debilitating condition with still very little epidemiologic data available. Older persons and parous women are particularly affected, but pathogenesis is not su ciently understood yet. Therapeutic measures for functional constipation should initially include a change in diet to a high-ber diet, adequate uid intake, and increased physical activity. However, it should be noted that there is little evidence that increased uid intake and physical activity signi cantly relieve symptoms of chronic constipation. If these measures are not successful, osmotic laxatives can be used. Stimulant laxatives are used as the nal drug escalation step [11]. The indication for surgical therapy results from subjective suffering and a loss of quality of life. Therefore, patient selection is particularly important to identify those who will bene t most from surgery. Surgical therapy should always be accompanied by stool regulating measures in order to avoid heavy pressing during defecation. Various surgical procedures for treatment are available and primarily consist of rectopexy with suture or mesh, which may be combined with a sigmoid resection. With the development of new and safer techniques, the majority of the transabdominal approaches are now performed laparoscopically [8].
Basically, perineal procedures are thought to be less invasive and complication-prone, but have worse functional outcomes compared with transabdominal procedures [2]. In this regard, laparoscopy and its advantages over open surgery are of particular importance. There is evidence that resection-rectopexy is superior to rectopexy without resection in terms of postoperative outcome, but this is at the expense of a higher complication rate [12]. Currently laparoscopic ventral mesh rectopexy and resection rectopexy are the two most used techniques worldwide [8].
The primary nding of this analysis is the improvement of constipation and gastrointestinal quality of life using CCCS and GIQLI after LRR in patients with rectal prolapse. Signi cant improvements were also observed in GIQLI subgroups of gastrointestinal symptoms, emotions, physical status, social dysfunction and effects of medical treatment. Five patients reported no or unaltered improvement in constipation and four reported no bene t for their quality of life. Improvement of constipation in literature was reported with 62, 69 and 82% [13]. Our own data support these results and showed an effectiveness of 80.0% after LRR in improvement of constipation. Mollen et al. could demonstrate that rectal mobilisation has statistically signi cant effect on colonic function. In their study total and segmental colonic transit times doubled suggesting reduced mobility of colon after rectal surgery [14]. Interestingly, all four patients with worse GIQLI also showed increased CCCS. Symptoms that improved in these patients were related to elimination of the prolapse and incontinence. Several single-center studies have been published on the functional outcome after LRR for rectal prolapse and the numbers of patients recruited range from 10 to 117 [15,16]. In the PROSPER trial 293 patients were included to compare laparoscopic, open abdominal and perineal procedures. No signi cant differences were reported regarding recurrence of the prolapse, incontinence, bowel function and quality of life. However, quality of life was clearly improved in all procedures [17]. Conversion rates from laparoscopic to open approach vary from 0% [18] to 7.2% [19]. Our own results reveal a conversion rate of 0%. Therefore, it can be claimed that conversion in LRR is low when performed at a high-volume centre for laparoscopic colorectal surgery. Overall complication rate of 16.0% (n = 4) was similar to previous studies [13]. Most complications were reported after LSRR with 50% (n = 3). However, validity of this nding is strongly limited by the small number of patients included in this subgroup. Furthermore, there was a signi cant difference in follow up with LSRR having the longest duration and LARR the shortest. This is explained by the fact that we have increasingly preferred LARR due to recent data suggesting more favorable results on the functional outcome after LARR compared to LPRR and LSRR. While observational and retrospective studies show good functional results and a low rate of complications and recurrence, evaluation of long-term outcome is still scarce. More data that focus on each particular laparoscopic procedure is needed to adequately compare different techniques. Therefore, an individualized approach is recommended for every patient considering age, comorbidities and the underlying morphological and functional disorders.

Conclusion
The present study strongly supports that laparoscopic resection rectopexy for rectal prolaps is safe, feasible, and very effective regarding both perioperative results and long-term functional outcome. Our results suggest that LRR signi cantly improves constipation in patients with outlet obstruction and clearly contributes to a higher quality of life.

Declarations
Funding: The authors did not receive support from any organization for the submitted work.