Professor Andre D’Hoore, who chaired both the Guidelines Synthesis report session and the keynote lecture by Evaghelos Xynos, talked with us about rectal prolapse before our annual meeting in Barcelona…
“There is a lot of debate on how to manage perianal Crohn’s disease. A recent publication in Gut on a ‘global consensus’ on classification, diagnosis and multidisciplinary treatment demonstrates the shortage of high quality randomised clinical trials for surgical options for patients with Crohn’s disease,” began Professor D’Hoore. “As a result, the Guidelines synthesis report session will present the guidelines, and perhaps more importantly, the gaps in the guidelines. This will indicate what data is missing, and guide us towards the studies needed to fill the gaps in our knowledge.”
He explained that international meetings such as the ESCP meeting in Barcelona provide colorectal surgeons with an excellent opportunity to identify those areas that need additional research and require guidelines in order to improve surgical outcomes across Europe.
According to D’Hoore, one of the current problems is the lack of multi-centre data with the vast majority of research and papers published coming from single centre studies. The dearth of multi-centre data means there is insufficient data and it is difficult to know whether the results from a single centre can be implemented across the wider surgical community.
“We will therefore try to build a body of evidence from which we can establish European guidelines for the surgical treatment for perianal and luminal Crohn’s disease,” he added. “This will be a joint project between the ESCP and Surgical ECCO that will begin work in the autumn through various working groups and the hope is to produce some pan-European guidelines.”
In addition, Professor D’Hoore stated that the notion of the working groups is to develop a platform to gather ideas and facilitate cooperation, particularly between high-volume centres throughout Europe to increase the knowledge base, via the Research Group of the ESCP.
“There are important questions to answer regarding the timing of surgery, which procedure and what medical treatment should a patient receive,” he added. “However, we must also look at new developments in the field, such as the LIFT procedure or use of adipose derived stem cells in fistula treatment, as there really are few data regarding these newly developed treatments.”
Rectal prolapse
“Rectal prolapse always throws up many opinions from different parts of the world and colleagues in Europe will have different views from colleagues from the US or Australia and Asia,” explained D’Hoore. “In Europe, there is quite a lot of interest in laparoscopic ventral rectopexy, whereas in the US there is little interest. The debate is further fuelled by medico-legal issues in regard to inappropriate use of non-absorbable meshes in the pelvis."
He stated that there is also a lot of discussion around whether a patient’s functional disorder is linked to the anatomical problem or whether the functional disorder is the primary cause of the dysfunction. More strict criteria are needed to propose LVR as a ‘functional’ operation especially in obstructed defaecation.
D’Hoore added that even when there is a clear case for surgery as in total rectal prolapse, there is still much debate about the optimum surgical approach and procedure; more long-term data is needed.
“All these questions underline the importance of gathering data across Europe. We know that the ten-year recurrence rates after LVR using a non-resorbable mesh equals 11%, so by gathering data we can look at the outcomes in different patient groups and try to ascertain the recurrences rates from biological meshes,” he concluded. “Therefore, I would encourage colleagues from across Europe to participate in the ESCP’s pan-European initiative so we can try to establish guidelines and clear patient algorithms of treatment.”