Tech Coloproctol DOI 10.1007/s10151-015-1279-4
CORRESPONDENCE
Lumbosacral discitis following laparoscopic ventral mesh rectopexy: a rare but potentially serious complication Z. Vujovic • E. Cuarana • K. L. Campbell N. Valentine • S. Koch • D. Ziyaie
•
Received: 3 October 2014 / Accepted: 28 January 2015 Ó Springer-Verlag Italia Srl 2015
Dear Sir, Laparoscopic ventral mesh rectopexy (LVMR) has widely become accepted as one of the most frequently used techniques in the treatment of full thickness rectal prolapse and increasingly for obstructive defaecation syndrome (ODS) [1–3]. Mesh is placed between the rectum and the vagina and secured with suture material to the ventral rectum and suspended from the sacral promontory using suture material or titanium tacks/screws, to ensure secure and sustainable anchorage. Whether to use synthetic or biological mesh has been the subject of recent controversy [4]. Whilst synthetic mesh is assumed to have a more durable longevity, erosion and infection have been perceived to occur more frequently and critics are in favour of biological alternatives. Recently [5], what type of suture material should be used to secure the mesh to the rectum has also been discussed; however, very little thought has been given to the mode in which mesh is suspended from the sacral promontory. Here, we present a rare but serious complication that directly resulted from the use of titanium screws for the fixation of mesh to the promontory. We believe that whilst this complication remains rare, awareness of it should be raised amongst the surgical community since early recognition and immediate treatment are the crucial steps in reducing the subsequent morbidity. Z. Vujovic (&) E. Cuarana K. L. Campbell S. Koch D. Ziyaie Department of Colorectal Surgery, Ninewells Hospital and Medical School, Dundee, Scotland, UK e-mail: [email protected] N. Valentine Department of Orthopaedics and Trauma Surgery, Ninewells Hospital and Medical School, Dundee, Scotland, UK
Case report A 50-year-old female presented with ODS as the result of a large symptomatic rectocoele. She underwent an uneventful LVMR, using biological mesh that was secured to the ventral rectum with non-absorbable sutures and to the sacral promontory using 6 titanium screws. She had received prophylactic antibiotics at induction and was discharged home on day 2. Whilst well for the initial 5–6 weeks with good functional outcome, she subsequently developed signs of malaise- and flue-like symptoms. Eleven weeks after the procedure she contacted the surgical team and was seen immediately. She was suffering from anorexia, lethargy, and low right-sided back pain. Her ODS symptoms had returned. Routine blood tests highlighted raised inflammatory markers. Blood cultures were negative. An urgent computed tomography (CT) scan of the abdomen and pelvis identified ‘‘multiple small metallic fragments within soft tissue swelling and oedema anterior to L5/S1 disc, with end plate erosion suggesting acute discitis’’ (Fig. 1). Urgent magnetic resonance imaging (MRI) of the lumbosacral spine confirmed ‘‘significant canal stenosis due to osteomyelitis and discitis’’ (Fig. 2). Intravenous antibiotics were started immediately, using recommendations from the departments of microbiology and infectious diseases departments, with a suboptimal response. Repeat MRI showed ‘‘further progression of infective discitis, with complete destruction of the intervening disc and enhancement of a small abscess collection extending both anteriorly and posteriorly from the disc space with compression of the theca’’ (Fig. 3). The patient was taken back to theatre in an attempt to obtain culture material and to remove the titanium screws. All six titanium screws were removed laparoscopically.
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Tech Coloproctol Fig. 1 Computed tomography scan of the abdomen and pelvis when the patient was readmitted
Fig. 2 Magnetic resonance imaging of the lumbosacral spine when the patient was readmitted
Technically, this was not difficult since the resulting granulation tissue and inflammatory material had rendered the screws mobile and loose (Fig. 4). Samples of the granulation tissue and all six screws were sent to microbiology laboratory, but no cultures were positive for infectious organisms.
123
Fig. 3 Repeat magnetic resonance imaging of the lumbosacral spine
Subsequently, the patient reported a substantial reduction in pain and there was normalisation of the inflammatory markers. However, with the loss of intervertebral space and collapse of facet joints the patient experienced immense pain during sitting and standing up from a lying down position. She continued intravenous antibiotics for 3 more months as an outpatient. Since there were no positive cultures from
Tech Coloproctol
Fig. 4 Intraoperative view of laparoscopic removal of the titanium screws
This case was the only one with complications in our series of 100 patients all of whom had biological mesh placement with titanium screws for fixation. The mesh was not removed and subsequently there were no adverse-related features. Only a handful of similar cases have been recorded in the literature, typically 4–8 weeks following surgery, including a case of long lasting sacral pain but no proven sacroiliiatis treated with steroids only [1, 6, 7]. Pyogenic spondylodiscitis has been reported by gynaecologists following sacral colpopexy [8]. These patients were treated with combination of antibiotics, some of whom had had mesh excision, debridement, and even resection of infected bone. One patient had to have surgical stabilisation of L5–S1. In our patient, although the samples taken were culture negative, the presentation and the radiological appearance were highly suggestive of acute infective discitis. It is not yet clear whether tacks and screws are superior to sutures. Since our experience we have made no change to our practice. We continue to use biological mesh and titanium screws. Whilst the complication remains rare, the resulting morbidity warrants awareness and mention in the consent process for prospective patients. Conflict of interest
None.
References
Fig. 5 X-ray of the spine 5 months after reintervention for removal of titanium screws
any of the material sent to the microbiology laboratory, including the titanium screws, the question whether this was an acute inflammatory or infective discitis remains unanswered. A plain X-ray 2 months later showed ‘‘spontaneous fusion of L5/S1’’ (Fig. 5).
1. D’Hoore A, Penninck F (2006) Laparoscopic Ventral mesh recto (colpo) pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc 20:1919–1923 2. Slawik S, Soulsby R, Carter H, Payne H, Dixon AR (2008) Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction. Colorectal Dis 10:138–143 3. Boons P, Collinson R, Cuningham C, Lindsey I (2009) Laparoscopic ventral rectopexy for external rectal prolapse improves and avoids de-novo constipation. Colorectal Dis 12:526–532 4. Ahmad M, Sileri P, Franceschilli L, Mercer-Jones L (2012) The role of biologics in pelvic floor surgery. Colorectal Dis 3:19–23 5. Formijne Jonkers HA, Van de Haar HJ, Draasima WA, Heggelman BGF, Consten ECJ, Broders IAMJ (2012) The optimal strategy for proximal mesh fixation during laparoscopic ventral rectopexy for rectal prolapse: an ex vivo study. Surg Endosc 26:2208–2212 6. Franceschilli L, Varvaras D, Capuano I et al (2015) Laparoscopic ventral rectopexy using biologic mesh for the treatment of obstructed defaecation syndrome and/or faecal incontinence in patients with internal rectal prolapse: a critical appraisal of the first 100 case. Tech Coloproctol. doi:10.1007/s10151-014-1255-4 7. Drassima WA, Van Eijek MM, Vos J, Consten ECJ (2011) Lumbar discitis after laparoscopic ventral mesh rectopexy for rectal prolapse. Int J Colorectal Dis 26:255–256 8. Propst K, Tunitskyu-Bitton E, Schimpf MO, Ridgeway B (2014) Pyogenic spondylodiscitis associated with sacral colpopexy and rectopexy: report of two cases and evaluation of the literature. Int Urogynecol J 25:21–31
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CORRESPONDENCE
Lumbosacral discitis following laparoscopic ventral mesh rectopexy: a rare but potentially serious complication Z. Vujovic • E. Cuarana • K. L. Campbell N. Valentine • S. Koch • D. Ziyaie
•
Received: 3 October 2014 / Accepted: 28 January 2015 Ó Springer-Verlag Italia Srl 2015
Dear Sir, Laparoscopic ventral mesh rectopexy (LVMR) has widely become accepted as one of the most frequently used techniques in the treatment of full thickness rectal prolapse and increasingly for obstructive defaecation syndrome (ODS) [1–3]. Mesh is placed between the rectum and the vagina and secured with suture material to the ventral rectum and suspended from the sacral promontory using suture material or titanium tacks/screws, to ensure secure and sustainable anchorage. Whether to use synthetic or biological mesh has been the subject of recent controversy [4]. Whilst synthetic mesh is assumed to have a more durable longevity, erosion and infection have been perceived to occur more frequently and critics are in favour of biological alternatives. Recently [5], what type of suture material should be used to secure the mesh to the rectum has also been discussed; however, very little thought has been given to the mode in which mesh is suspended from the sacral promontory. Here, we present a rare but serious complication that directly resulted from the use of titanium screws for the fixation of mesh to the promontory. We believe that whilst this complication remains rare, awareness of it should be raised amongst the surgical community since early recognition and immediate treatment are the crucial steps in reducing the subsequent morbidity. Z. Vujovic (&) E. Cuarana K. L. Campbell S. Koch D. Ziyaie Department of Colorectal Surgery, Ninewells Hospital and Medical School, Dundee, Scotland, UK e-mail: [email protected] N. Valentine Department of Orthopaedics and Trauma Surgery, Ninewells Hospital and Medical School, Dundee, Scotland, UK
Case report A 50-year-old female presented with ODS as the result of a large symptomatic rectocoele. She underwent an uneventful LVMR, using biological mesh that was secured to the ventral rectum with non-absorbable sutures and to the sacral promontory using 6 titanium screws. She had received prophylactic antibiotics at induction and was discharged home on day 2. Whilst well for the initial 5–6 weeks with good functional outcome, she subsequently developed signs of malaise- and flue-like symptoms. Eleven weeks after the procedure she contacted the surgical team and was seen immediately. She was suffering from anorexia, lethargy, and low right-sided back pain. Her ODS symptoms had returned. Routine blood tests highlighted raised inflammatory markers. Blood cultures were negative. An urgent computed tomography (CT) scan of the abdomen and pelvis identified ‘‘multiple small metallic fragments within soft tissue swelling and oedema anterior to L5/S1 disc, with end plate erosion suggesting acute discitis’’ (Fig. 1). Urgent magnetic resonance imaging (MRI) of the lumbosacral spine confirmed ‘‘significant canal stenosis due to osteomyelitis and discitis’’ (Fig. 2). Intravenous antibiotics were started immediately, using recommendations from the departments of microbiology and infectious diseases departments, with a suboptimal response. Repeat MRI showed ‘‘further progression of infective discitis, with complete destruction of the intervening disc and enhancement of a small abscess collection extending both anteriorly and posteriorly from the disc space with compression of the theca’’ (Fig. 3). The patient was taken back to theatre in an attempt to obtain culture material and to remove the titanium screws. All six titanium screws were removed laparoscopically.
123
Tech Coloproctol Fig. 1 Computed tomography scan of the abdomen and pelvis when the patient was readmitted
Fig. 2 Magnetic resonance imaging of the lumbosacral spine when the patient was readmitted
Technically, this was not difficult since the resulting granulation tissue and inflammatory material had rendered the screws mobile and loose (Fig. 4). Samples of the granulation tissue and all six screws were sent to microbiology laboratory, but no cultures were positive for infectious organisms.
123
Fig. 3 Repeat magnetic resonance imaging of the lumbosacral spine
Subsequently, the patient reported a substantial reduction in pain and there was normalisation of the inflammatory markers. However, with the loss of intervertebral space and collapse of facet joints the patient experienced immense pain during sitting and standing up from a lying down position. She continued intravenous antibiotics for 3 more months as an outpatient. Since there were no positive cultures from
Tech Coloproctol
Fig. 4 Intraoperative view of laparoscopic removal of the titanium screws
This case was the only one with complications in our series of 100 patients all of whom had biological mesh placement with titanium screws for fixation. The mesh was not removed and subsequently there were no adverse-related features. Only a handful of similar cases have been recorded in the literature, typically 4–8 weeks following surgery, including a case of long lasting sacral pain but no proven sacroiliiatis treated with steroids only [1, 6, 7]. Pyogenic spondylodiscitis has been reported by gynaecologists following sacral colpopexy [8]. These patients were treated with combination of antibiotics, some of whom had had mesh excision, debridement, and even resection of infected bone. One patient had to have surgical stabilisation of L5–S1. In our patient, although the samples taken were culture negative, the presentation and the radiological appearance were highly suggestive of acute infective discitis. It is not yet clear whether tacks and screws are superior to sutures. Since our experience we have made no change to our practice. We continue to use biological mesh and titanium screws. Whilst the complication remains rare, the resulting morbidity warrants awareness and mention in the consent process for prospective patients. Conflict of interest
None.
References
Fig. 5 X-ray of the spine 5 months after reintervention for removal of titanium screws
any of the material sent to the microbiology laboratory, including the titanium screws, the question whether this was an acute inflammatory or infective discitis remains unanswered. A plain X-ray 2 months later showed ‘‘spontaneous fusion of L5/S1’’ (Fig. 5).
1. D’Hoore A, Penninck F (2006) Laparoscopic Ventral mesh recto (colpo) pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc 20:1919–1923 2. Slawik S, Soulsby R, Carter H, Payne H, Dixon AR (2008) Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction. Colorectal Dis 10:138–143 3. Boons P, Collinson R, Cuningham C, Lindsey I (2009) Laparoscopic ventral rectopexy for external rectal prolapse improves and avoids de-novo constipation. Colorectal Dis 12:526–532 4. Ahmad M, Sileri P, Franceschilli L, Mercer-Jones L (2012) The role of biologics in pelvic floor surgery. Colorectal Dis 3:19–23 5. Formijne Jonkers HA, Van de Haar HJ, Draasima WA, Heggelman BGF, Consten ECJ, Broders IAMJ (2012) The optimal strategy for proximal mesh fixation during laparoscopic ventral rectopexy for rectal prolapse: an ex vivo study. Surg Endosc 26:2208–2212 6. Franceschilli L, Varvaras D, Capuano I et al (2015) Laparoscopic ventral rectopexy using biologic mesh for the treatment of obstructed defaecation syndrome and/or faecal incontinence in patients with internal rectal prolapse: a critical appraisal of the first 100 case. Tech Coloproctol. doi:10.1007/s10151-014-1255-4 7. Drassima WA, Van Eijek MM, Vos J, Consten ECJ (2011) Lumbar discitis after laparoscopic ventral mesh rectopexy for rectal prolapse. Int J Colorectal Dis 26:255–256 8. Propst K, Tunitskyu-Bitton E, Schimpf MO, Ridgeway B (2014) Pyogenic spondylodiscitis associated with sacral colpopexy and rectopexy: report of two cases and evaluation of the literature. Int Urogynecol J 25:21–31
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