Grossi, U., Lacy-Colson, J., Brown, S. R., Cross, S., Eldridge, S., Jordan, Mary, Mason, James, Norton, C., Scott, S. M., Stevens, N., Taheri, S. and Knowles, C. H. (2022) Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation. Techniques in Coloproctology, 26 . pp. 941-952. doi:10.1007/s10151-022-02633-w ISSN 1123-6337.

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Abstract

Background
The effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse is poorly evidenced. A UK-based multicenter randomized controlled trial was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up.

Methods
The randomized controlled trial was conducted from March 1, 2015 TO January 31, 2019. A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR (controls) with those who had undergone surgery. Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to three arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was defined as ≥ 1.0-point reduction in Patient Assessment of Constipation-Quality of Life and/or Symptoms (PAC-QOL and/or PAC-SYM) scores at 24 weeks. Secondary outcome measures included 14-day diary data, the Generalized Anxiety Disorder scale (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), St Marks incontinence score, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), the chronic constipation Behavioral Response to Illness Questionnaire (CC-BRQ), and the Brief Illness Perception Questionnaire (BIPQ).

Results
Of a calculated sample size of 114, only 28 patients (100% female) were randomized from 6 institutions (due mainly to national pause on mesh-related surgery). Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the three arms. Compared to baseline, significant reduction (improvement) in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (– 1.09 [95% CI – 1.76, – 0.41], p = 0.0019, and – 0.92 [– 1.52, – 0.32], p = 0.0029, respectively) in the 19 patients available for analysis (9 were excluded for dropout [n = 2] or missing primary outcome [n = 7]). There was a clinically significant long-term reduction in PAC-QOL scores (− 1.38 [− 2.94, 0.19], p = 0.0840 at 72 weeks). Statistically significant improvements in PAC-SYM scores persisted to 72 weeks (− 1.51 [− 2.87, − 0.16], p = 0.0289). Compared to baseline, no differences were found in secondary outcomes, except for significant improvements at 24 and 48 weeks on CC-BRQ avoidance behavior (− 14.3 [95% CI − 23.3, − 5.4], and − 0.92 [− 1.52, − 0.32], respectively), CC-BRQ safety behavior (− 13.7 [95% CI − 20.5, − 7.0], and − 13.0 [− 19.8, − 6.1], respectively), and BIPQ negative perceptions (− 16.3 [95% CI − 23.5, − 9.0], and − 10.5 [− 17.9, − 3.2], respectively).

Conclusions
With the caveat of under-powering due to poor recruitment, the study presents the first randomized trial evidence of short-term benefit of LVMR for internal rectal prolapse.

Trial registration
ISRCTN Registry (ISRCTN11747152).

Item Type:	Journal Article
Subjects:	R Medicine > RC Internal medicine R Medicine > RD Surgery R Medicine > RG Gynecology and obstetrics
Divisions:	Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH):	Constipation, Rectum -- Prolapse , Laparoscopy, Rectum -- Surgery -- Research
Journal or Publication Title:	Techniques in Coloproctology
Publisher:	Springer
ISSN:	1123-6337
Official Date:	December 2022
Dates:	Date Event December 2022 Published 19 May 2022 Available 1 May 2022 Accepted 2 March 2022 Submitted
Volume:	26
Number of Pages:	12
Page Range:	pp. 941-952
DOI:	10.1007/s10151-022-02633-w
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access (Creative Commons)
Date of first compliant deposit:	18 July 2022
Date of first compliant Open Access:	19 July 2022
RIOXX Funder/Project Grant:	Project/Grant ID RIOXX Funder Name Funder ID PGfAR: RP-PG-0612–20001 [NIHR] National Institute for Health Research http://dx.doi.org/10.13039/501100000272

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