Sutured posterior abdominal rectopexy with sigmoidectomy compared with Marlex rectopexy for rectal prolapse

Surgical Techniques for Rectal Prolapse

Complete rectal prolapse or rectal procidentia is a debilitating disease that presents with fecal incontinence, constipation, and rectal discharge. Definitive surgical techniques described for this disease include perineal procedures such as mucosectomy and rectosigmoidectomy, and abdominal procedures such as rectopexy with or without mesh and concomitant resection. The debate over these techniques regarding the lowest recurrence and morbidity rates, and the best functional outcomes for constipation or incontinence, has been going on for decades. The heterogeneity of available studies does not allow us to draw firm conclusions. This article aims to review the surgical techniques for complete rectal prolapse based on the current evidence base regarding surgical and functional outcomes.

Consensus Statement of the Italian Society of Colorectal Surgery (SICCR): management and treatment of complete rectal prolapse

Rectal prolapse, rectal procidentia, "complete" prolapse or "third-degree" prolapse is the full-thickness prolapse of the rectal wall through the anal canal and has a significant impact on quality of life. The incidence of rectal prolapse has been estimated to be approximately 2.5 per 100,000 inhabitants with a clear predominance among elderly women. The aim of this consensus statement was to provide evidence-based data to allow an individualized and appropriate management and treatment of complete rectal prolapse. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL and EMBASE. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Gastroenterology's Chronic Constipation Task Force. Five evidence levels were defined. The recommendations were graded A, B, and C.

Laparoscopic Posterolateral Rectopexy for the Treatment of Patients With a Full Thickness Rectal Prolapse: Experience With 63 Patients and Short-term Outcomes

Purpose

Although numerous procedures have been proposed for the treatment of patients with a rectal prolapse, the most effective operation has not yet been established. Minimal rectal mobilization can prevent constipation; however, it is associated with increased recurrence rates. We describe our novel method for a laparoscopic posterolateral rectopexy, which includes rectal mobilization with a posterior-right unilateral dissection, suture fixation to the sacral promontory with a polypropylene mesh (Optilene), and a mesorectal fascia propria that is as wide as possible. The present report describes our novel method and assesses the short-term outcomes of patients.

Methods

Between June 2014 and June 2017, 63 patients (28 males and 35 females) with a full-thickness rectal prolapse underwent a laparoscopic posterolateral (LPL) rectopexy. We retrospectively analyzed the clinical characteristics and postoperative complications in those patients. The outcome of surgery was determined by evaluating the answers on fecal incontinence questionnaires, the results of anal manometry preoperatively and 3 months postoperatively, the patients’ satisfaction scores (0–10), and the occurrence of constipation.

Results

No recurrence was reported during follow-up (3.26 months), and 3 patients reported postoperative complications (wound infection, postoperative sepsis, which was successfully treated with conservative management, and retrograde ejaculation). Compared to the preoperative baseline, fecal incontinence at three months postoperatively showed an overall improvement. The mean patient satisfaction score was 9.55 ± 0.10, and 8 patients complained of persistent constipation.

Conclusion

LPL rectopexy is a safe, effective method showing good functional outcomes by providing firm, solid fixation for patients with a full-thickness rectal prolapse.

Optimizing Treatment for Rectal Prolapse

Rectal prolapse is associated with debilitating symptoms and leads to both functional impairment and anatomic distortion. Symptoms include rectal bulge, mucous drainage, bleeding, incontinence, constipation, tenesmus, as well as discomfort, pressure, and pain. The only cure is surgical. The optimal surgical repair is not yet defined though laparoscopic rectopexy with mesh is emerging as a more durable approach. The chosen approach should be individually tailored, taking into account factors such as presence of pelvic floor defects and coexistence of vaginal prolapse, severe constipation, surgical fitness, and whether the patient has had a previous prolapse procedure. Consideration of a multidisciplinary approach is critical in patients with concomitant vaginal prolapse. Surgeons must weigh their familiarity with each approach and should have in their armamentarium both perineal and abdominal approaches. Previous barriers to abdominal procedures, such as age and comorbidities, are waning as minimally invasive approaches have gained acceptance. Laparoscopic ventral rectopexy is one such approach offering relatively low morbidity, low recurrence rates, and good functional improvement. However, proficiency with this procedure may require advanced training. Robotic rectopexy is another burgeoning approach which facilitates suturing in the pelvis. Successful rectal prolapse surgeries improve function and have low recurrence rates, though it is important to note that correcting the prolapse does not assure functional improvement.

Perineal Stapled Prolapse Resection

Perineal stapled prolapse resection is a new technique for external rectal prolapse introduced in 2007. We have done stapled perineal resection for 12 patients with full thickness rectal prolapse between January 2010 and April 2012. Elderly patients with comorbidities and young patients who want to avoid risk of nerve damage, with rectal prolapse up to 8-10 cms were included prospectively for perineal stapled rectal prolapse resection. Functional outcome, complications, operating time, and hospital stay were assessed in all patients. Perineal stapled prolapse resection was performed without major complications in a median operating time of 45 (range, 40-90) min and median Hospital stay was 3 days (3 to 11 days). Preoperative severe fecal incontinence and constipation improved postoperatively in 90 and 66 % of the patients, respectively, and there was no incidence of de novo onset or worsening of constipation in any of the patient. One patient developed small extra peritoneal collection which was managed by conservative treatment. No other complications occurred. At median follow-up of 36 months, all patients were well and showed no early recurrence of prolapse. Perineal stapled rectal prolapse resection is a new surgical procedure for external rectal prolapse, which is safe, easy, and quick to perform.

Rectal prolapse and intussusception

Rectal prolapse continues to be problematic for both patients and surgeons alike, in part because of increased recurrence rates despite several well-described operations. Patients should be aware that although the prolapse will resolve with operative therapy, functional results may continue to be problematic. This article describes the recommended evaluation, role of adjunctive testing, and outcomes associated with both perineal and abdominal approaches.

Colonic transit before and after resection rectopexy for full-thickness rectal prolapse

BACKGROUND

The objective of this study was to measure the change in colonic transit time after resection rectopexy for complete rectal prolapse.

METHODS

We prospectively carried out isotope colonic transit studies before resection rectopexy in 38 patients with full-thickness complete rectal prolapse and invited them to attend for a postoperative transit study at least 1 year after resection rectopexy.

RESULTS

Preoperatively, 27 (70 %) patients had abnormally prolonged colonic transit times, while 11 had normal colonic transit. Twenty-two (61 %) patients agreed to attend for a three-day colonic transit study. Resection rectopexy failed to correct delayed colonic transit in all patients with abnormal preoperative tests, while 4 patients developed new delayed transit and 2 with normal transit were unchanged.

CONCLUSIONS

The study suggests that most prolapse patients have a pan-colonic motility disorder that is not corrected by rectopexy and resection of most of the left colon. If resection rectopexy fails to correct abnormal transit, this study questions the rationale for continuing to offer resection and supports less invasive surgical procedures such as ventral rectopexy.

Laparoscopic ventral rectopexy for rectal prolapse and symptomatic rectocele: an analysis of 245 consecutive patients

AIM

This retrospective study aimed to determine functional results of laparoscopic ventral rectopexy (LVR) for rectal prolapse (RP) and symptomatic rectoceles in a large cohort of patients.

METHOD

All patients treated between 2004 and 2011 were identified. Relevant patient characteristics were gathered. A questionnaire concerning disease-related symptoms as well as the Cleveland Clinic Incontinence Score (CCIS) and Cleveland Clinic Constipation Score (CCCS) was sent to all patients.

RESULTS

A total of 245 patients underwent operation. Twelve patients (5%) died during follow-up and were excluded. The remaining patients (224 women, nine men) were sent a questionnaire. Indications for LVR were external RP (n = 36), internal RP or symptomatic rectocele (n = 157) or a combination of symptomatic rectocele and enterocele (n = 40). Mean age and follow-up were 62 years (range 22-89) and 30 months (range 5-83), respectively. Response rate was 64% (150 patients). The complication rate was 4.6% (11 complications). A significant reduction in symptoms of constipation or obstructed defaecation syndrome was reported (53% of patients before vs 19% after surgery, P < 0.001). Mean CCCS during follow-up was 8.1 points (range 0-23, SD ± 4.3). Incontinence was reported in 138 (59%) of the patients before surgery and in 32 (14%) of the patients after surgery, indicating a significant reduction (P < 0.001). Mean CCIS was 6.7 (range 0-19, SD ± 5.2) after surgery.

CONCLUSION

A significant reduction of incontinence and constipation or obstructed defaecation syndrome after LVR was observed in this large retrospective study. LVR therefore appears a suitable treatment for RP and rectocele with and without associated enterocele.

Surgical correction is ineffective for improvement of dyssynergic defecation in patients with rectal prolapse

BACKGROUND/AIMS

The patients with rectal prolapse suffer from not only a prolapse rectum but also associated dysfunction. However, most surgical techniques are successful regarding the prolapse, but either do not solve or even worsen defecation dysfunction. The purpose of this study was to investigate the functional and physiological results after surgical correction in patients with rectal prolapse.

METHODS

This study is a retrospective review of a single-institution experience. Patients with rectal prolapse who underwent anorectal manometry before and after Delorme's procedure were included. The primary outcomes measured were improvement of clinical symptoms and physiologic study.

RESULTS

Consecutive 19 patients with rectal prolapse (17 females, mean age of 68.1 ± 10.8 years) underwent anorectal manometry before and after Delorme's procedure. The two most prevalent symptoms before operation were rectal tenesmus (15/19, 78.9%) and excessive straining (13/19, 68.4%). The two most prevalent symptoms after operation were rectal tenesmus (14/19, 73.6%) and excessive straining (13/19, 68.4%). No significant differences in resting anal pressure, squeezing anal pressure, defecation index, and rectal sense were found postoperatively. However, vector asymmetry index before surgery was higher than that after surgery (35.0 vs. 32.0, P = 0.018). Ten patients (52.5%) had type I dyssynergic defecation before surgery. No improvement of dyssynergic pattern occurred after surgery.

CONCLUSIONS

In conclusion, dyssynergic defecation was not improved after reduction of rectal prolapse in patients with rectal prolapse. Further study about combination treatment with biofeedback therapy in these subgroups may be necessary.

Rectal prolapse

Rectal prolapse is a condition that usually requires surgical intervention to correct. Abdominal and perineal approaches are well described in the literature. Abdominal approaches have traditionally been reserved for young healthy patients, but this has been challenged by perineal approaches with excellent outcomes. Laparoscopic techniques have been shown to be effective and equivalent to traditional laparotomy techniques.

Laparoscopic Suture Rectopexy: An Effective Treatment for Complete Rectal Prolapse

BACKGROUND

The study was undertaken to validate the efficacy of laparoscopic suture rectopexy as the treatment modality of choice for complete prolapse of rectum.

METHODS

Data was prospectively collected and analyzed on 36 patients who underwent laparoscopic suture rectopexy for full thickness rectal prolapse between May 2006 to May 2008. There were 10 male and 26 female patients in this study with a mean age of 43.5 years. The pre and postoperative course of each patient was followed up with attention paid to ano-rectal manometery pressures, first bowel movement, hospital stay, duration of surgery, faecal incontinence, constipation, recurrence and morbidity. Mean follow up period was 12 months (range 1-24 months).

RESULT

One patient had conversion from laparoscopic to open surgery. while another had recurrence of prolapse in the follow up period. Mean duration of surgery was 115 (range 100-150) minutes. Postoperatively, the mean time for the first bowel movement was 40 (range 24-64) hours. Mean hospital stay was five (range 4-7) days. There was no significant postoperative complication except for one port site infection and one pelvic collection. Of the 20 patients who had varying degree of incontinence preoperatively, 16 (80%) showed improvement after surgery. Constipation was present in 15 (41%) patients preoperatively. Nine of these 15 patients (60%) improved as regards constipation after surgery.

CONCLUSION

Laparoscopic suture rectopexy is both safe and effective operation for the management of complete prolapse rectum. The procedure carries minimal morbidity and helps improve the problems of incontinence and constipation.

Rectal prolapse: review according to the personal experience

The aim of treatment of rectal prolapse is to control the prolapse, restore continence, and prevent constipation or impaired evacuation. Faced with a multitude of options, the choice of an optimal treatment is difficult. It is best tailored to patient and surgeon. Numerous procedures have been described and are generally categorized into perineal or abdominal approaches. In general, an abdominal procedure has associated with lower recurrence and better functional outcome than perineal procedures. The widespread success of laparoscopic surgery has led to the development of laparoscopic procedures in the treatment of complete rectal prolapse. In Korea, there has been a trend toward offering perineal procedures because of the high incidence of rectal prolapse in young males and its being a lesser procedure. Delorme-Thiersch procedure has appeal as a lesser procedure for patients of any age or risk category, especially for elderly low-risk patients, patients with constipation or evacuation difficulties, young males, and patients with symptomatic hemorrhoids or mucosal prolapse. Laparoscopic suture rectopexy is recommended for either low-risk female patients or patients who are concerned with postoperative aggravation of their incontinence.

Complete rectal prolapse in adults: clinical and functional results of delorme procedure combined with postanal repair

This study has been performed at the Department of General Surgery, Zagazig University Hospital and King Saud Hospital, Oniza, KSAduring the period from November 1998 to September 2008.Twentyadult patients (6 males and 14 females with a mean age of 55 years) with complete rectal prolapse were eligible for the study, Where Delorme's procedure and postanal repairwere combined. All patients presented with complete rectal prolapse at least 5 cm in length. The associated disorders included constipation (4 patients, 20%), variable degrees of incontinence (15 patients, 75%). Only one patient had no associated functional problems. The median follow up period was 65 months. There was no mortality and immediate postoperative complications developed in 4 patients (20%). Recurrence of the prolapse occurred in two patient. Eleven patients (73.3%) (11/17) with faecal incontinence showed postoperative improvement and 4 patients failed to improve. The 4 patients presented with constipation were all improved postoperatively. We conclude that the combination of Delorme's procedure and postanal repair in the treatment of complete rectal prolapse in adults is a safe procedure that corrects the anatomical defects and improves the functional outcome. We recommend use of this method in the treatment of complete rectal prolapse especially in the elderly who are complaining of faecal incontinence.

Comparison of perineal operations with abdominal operations for full-thickness rectal prolapse

BACKGROUND

We can divide surgery for rectal prolapse into two broad categories: abdominal and perineal. However, few studies compare the long-term outcomes and quality of life among operations for full-thickness rectal prolapse. The purpose of this study was to compare abdominal (AO) versus perineal (PO) procedures for the treatment of full-thickness rectal prolapse regarding recurrence rate, incontinence, constipation, and quality of life.

METHODS

Records of 177 operations from 1995 to 2001 were reviewed retrospectively. A telephone survey was attempted for all. Seventy-five (42%) responded to the Cleveland Clinic Incontinence Score (CCIS), KESS Constipation Score (KESS-CS), and SF-36 Quality of Life Score. Appropriate statistical analysis was performed.

RESULTS

For the 122 AO and 55 PO, there were no deaths. Mean follow-up was similar (PO 3.1 vs. AO 3.9 years; P = 0.306). As expected the PO patients were older (mean 69 vs. 55 years) and had higher ASA scores. Those undergoing PO had less procedural blood loss, operative time, hospital stay, and dietary restriction. The PO group also scored worse on the physical component of SF-36 (PO 33 vs. AO 39.6; P = 0.034). However, the rate of recurrent prolapse was significantly higher for the PO (PO 26.5% vs. AO 5.2%; P < 0.001). Complications, CCIS, KESS-CS, and SF-36 mental component were similar in both groups.

CONCLUSIONS

In full-thickness rectal prolapse, elderly, sick patients are selected for a perineal operation. The morbidity, functional outcomes, and quality of life are acceptable. However, the high recurrence rates make the perineal operation a second-best choice for younger, healthy patients.

Posterior sagittal approach for mesh rectopexy as a management of complete rectal in adults

OBJECTIVES

The aim of this study was to evaluate prospectively the functional outcome of posterior sagittal rectopexy with prolene mesh for rectal prolapse in young adults.

PATIENTS AND METHODS

The study was carried out on 32 patients, 21 were males (65.63%) presented with complete rectal prolapse with a mean age of 36.7 +/- (range, 28-45) years. All patients were subjected to preoperative colonoscopy, clinical assessment, and anorectal manometry, dynamic magnetic resonance defecography before and after posterior sagittal rectopexy with prolene mesh. Anal incontinence and constipation were evaluated using a Wexner scale and Cleveland clinic constipation score, respectively. The patients were followed for a mean of 18.7 +/- 6.4 months.

RESULTS

Fecal incontinence score recovered from 11.1 +/- 4.3 to 4.38 +/- 6.7, and constipation was improved in 13 out of 15 cases (86.57%). Straining anorectal angle (S-ARA) by MRI defecography improved from 127.2 +/- 5.9 degrees of 93.5 +/- 4.5 degrees (P < 0.05), perineal descent (PD) improved from 15.9 +/- 3.1 cm to 7.3 +/- 1.5 cm (P < 0.05). Maximal resting pressure (MRP) increased from 19.8 +/- 4.7 cm H(2)O to 43.5 +/- 3.9 cm H(2)O (P < 0.05). No mortality occurred, single case of recurrence of prolapse (3.22%), mucosal prolapse in two patients (6.44%), and mild wound infection in three patients (9.38%).

CONCLUSION

These findings indicate that posterior sagittal rectopexy with prolene mesh in adults with rectal prolapse is an effective technique, with excellent functional results and without major morbidities, but still long-term results are awaited.

Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation

OBJECTIVE

Abdominal rectopexy is ideal for otherwise healthy patients with rectal prolapse because of low recurrence, yet after posterior rectopexy, half of the patients complain of severe constipation. Resection mitigates this dysfunction but risks a pelvic anastomosis. The novel nerve-sparing ventral rectopexy appears to avoid postero-lateral rectal dissection denervation and thus postoperative constipation. We aimed to evaluate our functional results with laparoscopic ventral rectopexy.

METHOD

Consecutive rectal prolapse patients undergoing laparoscopic ventral rectopexy were prospectively assessed (Wexner Constipation and Faecal Incontinence Severity Index scores) pre-, 3 months postoperatively, and late (> 12 months).

RESULTS

Sixty-five consecutive patients with external rectal prolapse (median age 72 years, 34% > 80 years, median follow up 19 months) underwent laparoscopic ventral rectopexy. There was one recurrence (2%) and one conversion. Morbidity (17%) and mortality (0%) were low. Median operating time was 140 min and median length of stay 2 days. At 3 months, constipation was improved in 72% and mildly induced in 2% (median pre-and postoperative Wexner scores 9 vs 4, P < 0.0001). Continence was improved in 83% and mild incontinence was induced or worsened in 5% (median pre- and postoperative incontinence score 40 vs 4, P < 0.0001). Significant improvement in both constipation and incontinence (P < 0.0001) remained at median 24 months late follow-up.

CONCLUSION

Ventral rectopexy has a recurrent prolapse rate of < 5%, similar to that of posterior rectopexy. Its correction of preoperative constipation and avoidance of de novo constipation appear superior to historical functional results of posterior rectopexy. A laparoscopic approach allows low morbidity and short hospital stay, even in those patients over 80 years of age in whom a perineal approach is usually preferred for safety.

Functional outcome after perineal stapled prolapse resection for external rectal prolapse

Background

A new surgical technique, the Perineal Stapled Prolapse resection (PSP) for external rectal prolapse was introduced in a feasibility study in 2008. This study now presents the first results of a larger patient group with functional outcome in a mid-term follow-up.

Methods

From December 2007 to April 2009 PSP was performed by the same surgeon team on patients with external rectal prolapse. The prolapse was completely pulled out and then axially cut open with a linear stapler at three and nine o'clock in lithotomy position. Finally, the prolapse was resected stepwise with the curved Contour^® Transtar™ stapler at the prolapse's uptake. Perioperative morbidity and functional outcome were prospectively measured by appropriate scores.

Results

32 patients participated in the study; median age was 80 years (range 26-93). No intraoperative complications and 6.3% minor postoperative complications occurred. Median operation time was 30 minutes (15-65), hospital stay 5 days (2-19). Functional outcome data were available in 31 of the patients after a median follow-up of 6 months (4-22). Preoperative severe faecal incontinence disappeared postoperatively in 90% of patients with a reduction of the median Wexner score from 16 (4-20) to 1 (0-14) (P < 0.0001). No new incidence of constipation was reported.

Conclusions

The PSP is an elegant, fast and safe procedure, with good functional results.

Trial registration

ISRCTN68491191

A new technique for suture rectopexy without resection for rectal prolapse

BACKGROUND

We surmised that if rectopexy was performed without dissection of the lateral rectal stalks in patients with full-thickness rectal prolapse and normal preoperative transit, sigmoid resection may not be required. This study evaluated a new approach to abdominal suture rectopexy for rectal prolapse.

METHODS

A total of 81 patients (57 male, 24 female; median age 37 years, range 5-82 years) with rectal prolapse were assessed by clinical examination, anal manometry (maximum resting pressure, MRP, and squeeze pressure, MSP) and radioopaque marker transit studies. Of the 81 patients, 70 with normal preoperative transit underwent suture fixation alone, without resection, performed under spinal anaesthesia, through a 7-cm transverse left lower quadrant incision gaining access to the presacral space via a left pararectal "window", preserving the lateral stalks.

RESULTS

Average surgical time was 50 min, mortality was zero, and morbidity was 9% (three patients with wound infection, four with urinary retention). Anal incontinence improved in 43 of 53 patients (81%, p=0.001). MRP and MSP had improved at 3 months after surgery: MRP from a mean of 27.6+/-1.4 mmHg (range 2-30 mmHg) before surgery to 32.5+/-2.21 mmHg (2-60 mmHg) after surgery (p=0.008); MSP from 69.25+/-6.4 mmHg (8-153 mmHg) before surgery to 79+/-4.77 mmHg (35-157 mmHg) after surgery (p=0.001).. Transit was unchanged in 18 of 20 patients (90%) who were evaluated before and after surgery; none was constipated after surgery. At 56 months, prolapse had recurred in five patients (7%).

CONCLUSION

Abdominal suture rectopexy with a left pararectal approach without sigmoid resection in those with normal preoperative transit resulted in an improvement in anal incontinence and satisfactory long-term control of prolapse. The operation did not alter transit and did not result in significant constipation.

Overt rectal prolapse and fecal incontinence

PURPOSE

Rectal prolapse is frequently associated with fecal incontinence; however, the relationship is questionable. The study was designed to evaluate fecal incontinence in a large consecutive series of patients who suffered from rectal prolapse, focusing on both past history, anal physiology, and imaging.

METHODS

Eighty-eight consecutive patients who suffered from an overt rectal prolapse (72 women, 16 men; mean age, 51.1 +/- 19.5 years) as a main symptom were analyzed; 48 patients also experienced fecal incontinence compared with 40 without incontinence. Logistic regression analyses were performed.

RESULTS

The two groups of patients did not differ with respect to parity, weekly stool frequency, main duration of symptoms before referral, occurrence of dyschezia, and digital help to defecate. Patients with prolapse who were older than 45 years (odds ratio (OR), 4.51 (1.49-13.62); P = 0.007) and those with a past history of hemorrhoidectomy (OR, 9.05 (1.68-48.8); P = 0.01) were significantly more incontinent. Incontinent group showed frequent internal anal sphincter defect compared with the continent group (60 vs. 6.2 percent; P = 0.0018).

CONCLUSIONS

In patients with overt rectal prolapse, the occurrence of fecal incontinence needs special consideration for age and previous hemorrhoid surgery as causative factors. Anal weakness and sphincter defects are frequently observed.

Management of complex pelvic floor disorders in a multidisciplinary pelvic floor clinic

OBJECTIVE

To identify symptom clusters, management strategies and survey patient satisfaction in our combined multidisciplinary pelvic floor clinic (PFC).

METHOD

Retrospective cohort study, patient satisfaction questionnaire.

SAMPLE

Secondary and tertiary referrals with complex pelvic floor disorders.

MAIN OUTCOME MEASURES

symptom clusters and treatment received; patient satisfaction.

RESULTS

A total of 113 new cases over a 3-year period. There were two main symptom clusters: (i) obstructed defaecation with rectoceles (n = 55); of these, 23 had abdominal sacrocolpopexy with rectopexy, six had transvaginal rectocele repairs; and (ii) of the 33 with double incontinence, 10 had anal sphincter repairs, five had tension-free vaginal tapes and two had colposuspensions. Patient satisfaction audit: 73% found the care to be excellent/good, 12% satisfactory and 6% unsatisfactory.

CONCLUSION

Combined PFCs led to a more pragmatic approach in treating patients' symptoms. Combined surgery was undertaken in one-fourth of patients and is associated with cost savings and a single recuperation period. Overall, patients rated this service very highly.

Rectal prolapse

INTRODUCTION

Rectal prolapse, or procidentia, is defined as a protrusion of the rectum beyond the anus. It commonly occurs at the extremes of age. Rectal prolapse frequently coexists with other pelvic floor disorders, and patients have symptoms associated with combined rectal and genital prolapse. Few patients, a lack of randomized trials and difficulties in the interpretation of studies of anorectal physiology have made the understanding of this disorder difficult.

METHODS OF TREATMENT

Surgical management is aimed at restoring physiology by correcting the prolapse and improving continence and constipation, whereas in patients with concurrent genital and rectal prolapse, an interdisciplinary surgical approach is required. Operation should be reserved for those patients in whom medical treatment has failed, and it may be expected to relieve symptoms. Numerous surgical procedures have been suggested to treat rectal prolapse. They are generally classified as abdominal or perineal according to the route of access. However, the controversy as to which operation is appropriate cannot be answered definitively, as the extent of a standardized diagnostic assessment and the types of surgical procedures have not been identified in published series.

LITERATURE REVIEW

This review encompasses rectal prolapse, including aetiology, symptoms and treatment. The English-language literature about rectal prolapse was identified using Medline, and additional cited works not detected in the initial search were obtained. Articles reporting on prospective and retrospective comparisons and case reports were included.

Surgery for rectal prolapse: Orr-Loygue ventral rectopexy with limited dissection prevents postoperative-induced constipation without increasing recurrence

PURPOSE

Abdominal rectopexy is the preferred surgical technique for the treatment of total rectal prolapse. In many reported series, its results are impaired by induced constipation. Lateral rectal ligaments preservation could prevent constipation but increase recurrence rates. We report anatomic and functional results of abdominal Orr-Loygue ventral rectopexy with dissection limited to anterior and posterior rectal wall.

METHODS

Consecutive patients with total rectal prolapse or intra-anal rectal prolapse associated to fecal incontinence or outlet obstruction were treated by abdominal rectopexy. Recurrences, correction of symptoms, and induced constipation were prospectively analyzed.

RESULTS

Seventy-three patients were treated between 1993 and 2004. Recurrence was observed in 3 of 73 patients (4.1 percent) after a mean follow-up period of 28.6 (range, 6-84) months. Overall patient satisfaction (correction of prolapse, incontinence, and/or outlet obstruction) after the procedure was classified in three categories: Cured: n = 45 (61.6 percent); Improved: n = 24 (32.9 percent); Failure: n = 4 (5.5 percent). Postoperative constipation appeared in 2 of 36 (5.5 percent) preoperatively nonconstipated patients and worsened in 2 of 37 (5.4 percent) preoperatively constipated patients.

CONCLUSIONS

Orr-Loygue abdominal ventral rectopexy with limited dissection and preservation of rectal lateral ligaments is a safe and effective procedure for the treatment of complete rectal prolapse, or internal prolapse associated with fecal incontinence or outlet obstruction. Preservation of lateral ligaments seems to prevent postoperative constipation without increasing the risk of prolapse recurrence.

Laparoscopic rectal prolapse surgery combined with short hospital stay is safe in elderly and debilitated patients

BACKGROUND

We report the results of patients treated from January 2000 to June 2004 for full-thickness rectal prolapse with trans-abdominal surgery in Helsinki.

METHODS

Sixty-five of 75 patients were treated laparoscopically, with a 6% conversion rate. Ten patients were operated on openly. Half of the patients were scored as American Society for Anesthesiologists III or IV.

RESULTS

The operation time was similar in the laparoscopic and the open rectopexy procedures (p = 0.15), whereas laparoscopic resection rectopexy was more time-consuming compared to the open procedure (p = 0.007). Intraoperative bleeding during laparoscopic surgery was minimal in comparison to open surgery (p = 0.006). Patients treated laparoscopically had a shorter median hospital stay than those treated with an open procedure (rectopexy, 3 and 7 days, respectively; resection rectopexy, 4 and 7.5 days, respectively) (p < 0.00001). There was no mortality and minor morbidity. During follow-up, there were two prolapse recurrences. All surgical techniques improved fecal continence considerably. Eighty-four percent of rectopexy patients and 92% of resection rectopexy patients considered the surgical outcome to be excellent or good.

CONCLUSIONS

Both rectopexy and resection rectopexy cure prolapse with good results and can be performed safely in older and debilitated patients. The laparoscopic approach enables a shortened hospital stay and is well tolerated in elderly patients.

[Rectal prolapse. Abdominal or perineal approach? Current situation]

Rectal prolapse is a major challenge for the surgeon who has to resolve the anatomical problem and the functional disturbances in the same procedure. Abdominal procedures are the most appropriate in young patients, and the most common technique is rectopexia with or without resection. The use of mesh or sutures provides the same results and the choice depends on the surgeon's preference. Laparoscopic surgery has been demonstrated to have similar efficacy to conventional surgery and may become the option of the future. The perineal approach is the best option in elderly patients and in those with associated morbidity; the Delorme technique is simple to carry out, but rectosigmoidectomy provides better results.

Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study

BACKGROUND

Laparoscopic repair (LR) of rectal prolapse is potentially associated with earlier recovery and lower perioperative morbidity, as compared with open transabdominal repair (OR). Data on the long-term recurrence rate and functional outcome are limited.

METHODS

Perioperative data on rectal prolapse in relation to all LRs performed between December 1991 and April 2004 were prospectively collected. The LR patients were matched by age, gender, and procedure type with OR patients who underwent surgery during the same period. Patients with previous complex abdominal surgery or a body mass index exceeding 40 were excluded from the study. Data on recurrence rate, bowel habits, continence, and satisfaction scores were collected using a telephone survey.

RESULTS

A total of 111 patients (age, 56.8 +/- 18.1 years; female, 87%) underwent attempted LR. An operative complication deferred repair in two cases. Among the 111 patients, 42 had posterior mesh fixation, and 67 had sutured rectopexy (32 patients with sigmoid colectomy for constipation). Eight patients (7.2%) had conversion to laparotomy. Matching was established for 86 patients. The LR patients had a shorter hospital stay (mean, 3.9 vs 6.0 days; p < 0.0001). The 30-day reoperation and readmission rates were similar for the two groups. The rates for recurrence requiring surgery were 9.3% for LR and 4.7% for OR (p = 0.39) during a mean follow-up period of 59 months. An additional seven patients in each group reported possible recurrence by telephone. Postoperatively, 35% of the LR patients and 53% of the OR patients experienced constipation (p = 0.09). Constipation was improved in 74% of the LR patients and 54% of the OR patients, and worsened, respectively, in 3% and 17% (p = 0.037). The postoperative incontinence rates were 30% for LR and 33% for OR (p = 0.83). Continence was improved in 48% of the LR patients and 35% of the OR patients, and worsened, respectively, in 9% and 18% (p = 0.22). The mean satisfaction rates for surgery (on a scale of 0 to 10) were 7.3 for the LR patients and 8.1 for the OR patients (p = 0.17).

CONCLUSIONS

The hospital stay is shorter for LR than for OR. Both functional results and recurrent full-thickness rectal prolapse were similar for LR and OR during a mean follow-up period of 5 years.

Recurrence rates after abdominal surgery for complete rectal prolapse: a multicenter pooled analysis of 643 individual patient data

PURPOSE

This study was designed to determine what impact surgical technique, means of access, and method of rectopexy have on recurrence rates following abdominal surgery for full-thickness rectal prolapse.

METHODS

Consecutive individual patient data on age, gender, surgical technique (mobilization-only, mobilization-resection-pexy, or mobilization-pexy), means of access (open or laparoscopic), rectopexy method (suture or mesh), follow-up length, and recurrences were collected from 15 centers performing abdominal surgery for full-thickness rectal prolapse between 1979 and 2001. Recurrence was defined as the presence of full-thickness rectal prolapse after abdominal surgery. Chi-squared test and Cox proportional hazards regression analysis were used to assess statistical heterogeneity. Recurrence-free curves were generated and compared using the Kaplan-Meier method and log-rank test, respectively.

RESULTS

Abdominal surgery consisted of mobilization-only (n = 46), mobilization-resection-pexy (n = 130), or mobilization-pexy (n = 467). There were 643 patients. After excluding center 8, there was homogeneity on recurrence rates among the centers with recurrences (n = 8) for age (hazards ratio, 0.6; 95 percent confidence interval, 0.2-1.7; P = 0.405), gender (hazards ratio, 0.6; 95 percent confidence interval, 0.1-2.3; P = 0.519), and center (hazards ratio, 0.3; 95 percent confidence interval, 0.1-1.5; P = 0.142). However, there was heterogeneity between centers with (n = 8) and without recurrences (n = 6) for gender (P = 0.0003), surgical technique (P < 0.0001), means of access (P = 0.01), and rectopexy method (P < 0.0001). The median length of follow-up of individual centers varied from 4 to 127 months (P < 0.0001). There were 38 recurrences at a median follow-up of 43 (range, 1-235) months. The pooled one-, five-, and ten-year recurrence rates were 1.06, 6.61, and 28.9 percent, respectively. Age, gender, surgical technique, means of access, and rectopexy method had no impact on recurrence rates.

CONCLUSIONS

Although this study is likely underpowered, the impact of mobilization-only on recurrence rates was similar to that of other surgical techniques.

Laparoscopically-assisted resection rectopexy for rectal prolapse: ten years' experience

PURPOSE

This study has been undertaken to audit a single-center experience with laparoscopically-assisted resection rectopexy for full-thickness rectal prolapse. The clinical outcomes and long-term results were evaluated.

METHODS

The data were prospectively collected for the duration of the operation, time to passage of flatus postoperatively, hospital stay, morbidity, and mortality. For follow-up, patients received a questionnaire or were contacted. The data were divided into quartiles over the study period, and the differences in operating time and length of hospital stay were tested using the Kruskal-Wallis test.

RESULTS

Between March 1992 and October 2003, a total of 117 patients underwent laparoscopic resection rectopexy for rectal prolapse. The median operating time during the first quartile (representing the early experience) was 180 minutes compared with 110 minutes for the fourth quartile (Kruskal-Wallis test for operating time = 35.523, 3 df, P < 0.0001). Overall morbidity was 9 percent (ten patients), with one death (<1 percent). One patient had a ureteric injury requiring conversion. One minor anastomotic leak occurred, necessitating laparoscopic evacuation of a pelvic abscess. Altogether, 77 patients were available for follow-up. The median follow-up was 62 months. Eighty percent of the patients reported alleviation of their symptoms after the operation. Sixty-nine percent of the constipated patients experienced an improvement in bowel frequency. No patient had new or worsening symptoms of constipation after surgery. Two (2.5 percent) patients had full-thickness rectal prolapse recurrence. Mucosal prolapse recurred in 14 (18 percent) patients. Anastomotic dilation was performed for stricture in five (4 percent) patients.

CONCLUSIONS

Laparoscopically-assisted resection rectopexy for rectal prolapse provides a favorable functional outcome and low recurrence rate. Shorter operating time is achieved with experience. The minimally invasive technique benefits should be considered when offering rectal prolapse patients a transabdominal approach for repair, and emphasis should now be on advanced training in the laparoscopic approach.

Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse

BACKGROUND

Postoperative constipation is a common problem with most mesh suspension techniques used to correct rectal prolapse. Autonomic denervation of the rectum subsequent to its complete mobilization has been suggested as a contributory factor. The aim of this study was to assess the long-term outcome of patients who underwent a novel, autonomic nerve-sparing, laparoscopic technique for rectal prolapse.

METHODS

Between 1995 and 1999, 42 patients had laparoscopic ventral rectopexy for total rectal prolapse. The long-term results after a median follow-up of 61 (range 29-98) months were analysed.

RESULTS

There were no major postoperative complications. Late recurrence occurred in two patients. In 28 of 31 patients with incontinence there was a significant improvement in continence. Symptoms of obstructed defaecation resolved in 16 of 19 patients. During follow-up, new onset of mild obstructed defaecation was noted in only two patients. Symptoms suggestive of slow-transit colonic obstipation were not induced.

CONCLUSION

Laparoscopic ventral rectopexy is an effective technique for the correction of rectal prolapse and appears to avoid severe postoperative constipation. The ventral position of the prosthesis may explain the beneficial effect on symptoms of obstructed defaecation.

Prosthetic rectopexy to the pelvic floor and sigmoidectomy for rectal prolapse

BACKGROUND

Full thickness rectal prolapse in young adults with normal pelvic floor is a disease in which the rectum is exceedingly long and mobile. Surgical treatment should correct both anatomical defects by combined rectopexy and colonic resection, which is expected to be less constipating than rectopexy alone. The aim of this study was to describe an original procedure of rectopexy to the pelvic floor with prosthetic material combined with sigmoid resection, and to evaluate prospectively anatomical and functional results.

METHODS

Thirty-five patients (30 women) of median age 44 years (range 18 to 74) were operated on for full thickness rectal prolapse with normal pelvic floor. The rectum was mobilized posteriorly without division of the lateral ligaments and attached to the pelvic floor previously repaired with a nonabsorbable mesh. The sigmoid colon was resected with hand-sewn anastomosis. Clinical results were assessed by a questionnaire.

RESULTS

There were no deaths or any septic or anastomotic complications. Small bowel obstruction was corrected laparoscopically in 1 patient. Mean hospital stay was 8 days (range 6 to 14). Mean follow-up was 34 months (range 10 to 93). No recurrence was seen. Preoperatively, 33 patients (94%) complained of constipation mainly with emptying problems (21 patients) and 25 patients (71.5%) were incontinent. Postoperatively, no constipated or incontinent patient's condition worsened. Rectal emptying was restored in 17 patients (81%). Eighteen incontinent patients (72%) regained full continence. On the other hand, 2 patients with normal bowel function worsened and 1 patient with an altered rectal compliance after Delorme's operation became incontinent.

CONCLUSIONS

In young adults with rectal prolapse and normal pelvic floor undergoing prosthetic rectopexy and sigmoid resection (a) morbidity was low, (b) anatomical control was obtained in all cases, (c) emptying problems were corrected, and (d) deleterious effects are likely to occur if they had no constipation before operation or if rectal compliance was previously altered.

Rectal sensory perception in females with obstructed defecation

PURPOSE

Parasympathetic afferent nerves are thought to mediate rectal filling sensations. The role of sympathetic afferent nerves in the mediation of these sensations is unclear. Sympathetic nerves have been reported to mediate nonspecific sensations in the pelvis or lower abdomen in patients with blocked parasympathetic afferent supply. It has been reported that the parasympathetic afferent nerves are stimulated by both slow ramp (cumulative) and fast phasic (intermittent) distention of the rectum, whereas the sympathetic afferent nerves are only stimulated by fast phasic distention. Therefore, it might be useful to use the two distention protocols to differentiate between a parasympathetic and sympathetic afferent deficit.

METHODS

Sixty control subjects (9 males; median age, 48 (range, 20-70) years) and 100 female patients (median age, 50 (range, 18-75) years) with obstructed defecation entered the study. Rectal sensory perception was assessed with an "infinitely" compliant polyethylene bag and a computer-controlled air-injection system. This bag was inserted into the rectum and inflated with air to selected pressure levels according to two different distention protocols (fast phasic and slow ramp). The distending pressures needed to evoke rectal filling sensations, first sensation of content in the rectum, and earliest urge to defecate were noted, as was the maximum tolerable volume.

RESULTS

In all control subjects, rectal filling sensations could be evoked. Twenty-one patients (21 percent) experienced no sensation at all in the pressure range between 0 and 65 mmHg during either slow ramp or fast phasic distention. The pressure thresholds for first sensation, earliest urge to defecate, and maximum tolerable volume were significantly higher in patients with obstructed defecation (P < 0.001). In each subject, the pressure thresholds for first sensation, earliest urge to defecate, and maximum tolerable volume were always the same, regardless of the type of distention.

CONCLUSION

Rectal sensory perception is blunted or absent in the majority of patients with obstructed defecation. The observation that this abnormality can be detected by both distention protocols suggests that the parasympathetic afferent nerves are deficient. Because none of the patients experienced a nonspecific sensation in the pelvis or lower abdomen during fast phasic distention, it might be suggested that the sympathetic afferents are also deficient. This finding implies that it is not worthwhile to use different distention protocols in patients with obstructed defecation.

Functional results two years after laparoscopic rectopexy

BACKGROUND

Rectopexy is one of the accepted treatment options for full-thickness rectal prolapse, but the details of the technique remain controversial. This unit has adopted a laparoscopic approach as an alternative to open surgery, and has used three techniques: mesh, suture, and resection. This retrospective study compares the long-term outcome.

METHODS

From 1993 to 1995, 14 patients underwent a laparoscopic posterior mesh rectopexy. From 1996 to 1999, 34 patients underwent laparoscopic suture rectopexy with (n = 18) or without sigmoid resection (n = 16).

RESULTS

There was no postoperative mortality, and morbidity was similar in the three groups, ranging from 11 to 19%. The mean follow-up was 47, 24, and 20 months for mesh, suture, and resection rectopexy, respectively. During follow-up, 1 patient in each group developed mucosal prolapse. There was no difference between the three groups for incontinence rate, which improved in more than 75% of patients who had impaired continence preoperatively. Postoperative constipation was observed in 2 patients (11%) after resection rectopexy, in 10 (62%) after suture rectopexy (P < 0.01 versus resection), and in 9 (64%) after mesh rectopexy (P < 0.01 versus resection).

CONCLUSIONS

Our results show that the addition of sigmoid resection to laparoscopic rectopexy is safe and could contribute to reduce the risk of severe constipation after operation. Laparoscopic mesh rectopexy confers no advantage over the sutured technique, which we now use as our fixation method of choice.

The Altemeier repair: outpatient treatment of rectal prolapse

PURPOSE

Rectal prolapse typically occurs in elderly patients, who are often poor surgical candidates because of the presence of multiple comorbidities. Abdominal approaches to procidentia have low recurrence rates but are associated with higher rates of morbidity and mortality. Perineal rectosigmoidectomy (Altemeier repair) is a safe and effective approach to the treatment of rectal prolapse and can be done as an outpatient procedure. In this article, the results of a series of 63 consecutive Altemeier repairs are presented.

METHODS

Between February 1993 and December 1999, 63 patients (61 females) underwent Altemeier repair of rectal prolapse. The mean patient age was 79 years. Preoperative, intraoperative, and postoperative data were collected and analyzed for all patients.

RESULTS

Median follow-up was 20.8 months. Seventy percent of patients were given a regional or local anesthetic. The average resected specimen length was 11.6 cm, and 83 percent of anastomoses were stapled. Sixty-two percent of patients were discharged home on the day of surgery, and 80 percent were home within 24 hours. Complications occurred in 10 percent of patients, but there was no perioperative mortality. There was a 6.4 percent recurrence rate, and all recurrences were successfully treated with repeat Altemeier repair. All 63 patients had complete objective resolution of prolapse, and 87 percent had subjective improvement after repair.

CONCLUSIONS

Altemeier repair of rectal prolapse is safe, produces minimal discomfort, and does not require a general anesthetic. It is ideally suited to be done on an outpatient basis, as was done in the majority of patients in our series. The recurrence rate is slightly higher than with abdominal resections, but morbidity and cost are lower, and repeat perineal resections are easily and safely performed.

Laparoscopic suture rectopexy without resection is effective treatment for full-thickness rectal prolapse

PURPOSE

The study was undertaken to evaluate the role of laparoscopic suture rectopexy without resection as a safe and effective treatment for full-thickness rectal prolapse.

METHOD

Data were prospectively collected and analyzed on 25 patients who underwent laparoscopic rectopexy without resection for full-thickness rectal prolapse between October 1994 and July 1998. Four patients had conversions from laparoscopic to open surgery. Two patients had recurrent prolapse previously managed by Delorme's procedure. Another two patients had solitary rectal ulcer syndrome associated with their full-thickness rectal prolapse. There were a total of three males. Mean age was 72 (range, 37-89) years. The preoperative and postoperative course of each patient was followed up, with attention paid to first bowel movement, hospital stay, duration of surgery, fecal incontinence, constipation, recurrent prolapse, morbidity, and mortality. Follow-up was made by clinic appointments and, if necessary, by telephone review.

RESULTS

Median follow-up period was 26 (range, 1-41) months. Mean duration of surgery was 96 (range, 50-150) minutes. Postoperatively, the median time for first bowel movement was four (range, 2-10) days. Median hospital stay was seven (range, 3-23) days. Overall, 15 patients (60 percent) either improved or remained unchanged with respect to continence. There was an improvement in 10 of 20 patients (50 percent) among those with continence Grade 2 or more (P < 0.05). Seven patients (28 percent) remained incontinent. No patient became more incontinent after surgery. Constipation, which was present in 9 patients (36 percent) preoperatively, affected 11 patients (44 percent) after rectopexy (P > 0.05; not significant). Postoperative morbidity included a port site hernia and deep venous thrombosis in one patient, a repaired rectal perforation, a retroperitoneal hematoma with prolonged ileus (1 case), and a superficial wound infection (1 case). One patient with solitary rectal ulcer syndrome in the laparoscopic surgery group remained unhealed despite resolution of the rectal prolapse after rectopexy and required abdominoperineal resection. Two patients (laparoscopic surgery = 1 and open surgery = 1) had severe constipation after surgery and both required loop colostomies. There were no cases of operative mortality or recurrent prolapse.

CONCLUSION

Laparoscopic suture rectopexy without resection is both safe and effective in this frequently frail population and offers a minimally invasive approach that may have potential advantages for selected groups of patients with full-thickness rectal prolapse.

Surgery for complete rectal prolapse in adults

BACKGROUND

Complete rectal prolapse is a debilitating condition, which affects both the very young and the elderly and can cause faecal incontinence. The range of surgical methods available to correct the underlying anal sphincter or pelvic floor defects in complete rectal prolapse poses the question about the choice of the best operation.

OBJECTIVES

To determine the effects of surgery on the treatment of rectal prolapse in adults. The following specific issues have been addressed: I. Whether surgical intervention is better than no treatment; II. Whether an abdominal approach to surgery is better then a perineal approach; III. Whether one method for performing rectopexy is better than another; IV. Whether laparoscopic access is better than open access for surgery; V. Whether resection should be included in the procedure.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register, the Cochrane Colorectal Cancer Group trials register, the Cochrane Controlled Trials Register (Issue 2, 1999), Medline (up to March 1999), Embase (1998 up to January 1999), Sigle (1980 up to December 1996), Biosis (1998 up to March 1999), SCI (1998 up to March 1999), ISTP (1982 up to March 1999) and the reference lists of relevant articles. We hand searched the British Journal of Surgery 1995-8, and the Diseases of the Colon and Rectum 1995-8. We also searched the proceedings of the Association of Coloproctology, meeting 1999. Date of the most recent searches: March 1999.

SELECTION CRITERIA

All randomised or quasi-randomised trials of surgery in the management of rectal prolapse.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies from the literature, extracted data and assessed the methodological quality of eligible trials. The three primary outcome measures were number of patients with recurrent rectal prolapse, or residual mucosal prolapse or faecal incontinence.

MAIN RESULTS

Eight trials were included with a total of 264 participants. No trial included a group receiving no treatment, or anal encirclement, or Delormes procedure, or laparoscopic suture rectopexy, or laparoscopic resection rectopexy. One trial (20 participants) compared both perineal and abdominal resection rectopexy with pelvic floor repair; four trials (175 participants) compared different types of open rectopexy techniques; one trial (21 participants) compared laparoscopic with open mesh rectopexy; and two trials included comparisons between open resection rectopexy and rectopexy alone. In all comparisons data were few. There were no detectable differences in recurrent prolapse between abdominal and perineal approaches, although there was a suggestion that residual faecal incontinence was less common after abdominal surgery. There were no detectable differences between the methods used for fixation during rectopexy. Division, rather than preservation, of the lateral ligaments was associated with less recurrent prolapse but more post-operative constipation, although these findings were found in small numbers. There were too few data with which to compare laparoscopic with open surgery. Bowel resection during rectopexy was associated with lower rates of constipation, but again numbers were small.

REVIEWER'S CONCLUSIONS

The small number of relevant trials identified, and their small sample sizes together with other methodological weaknesses severely limit the usefulness of this review for guiding practice. It was impossible to identify or refute clinically important differences between the alternative surgical operations. Larger rigorous trials are needed to improve the evidence with which to define optimum surgical treatment.

The effect of abdominal rectopexy with mesh on anal sphincter and bowel function in patients with complete rectal prolapse; special reference to age of patient

OBJECTIVE

 The main source of concern in patients with rectal prolapse is usually incontinence and constipation developing post-operatively. It has been claimed that sphincter pressures improve only after non-implant surgery. The aim of this study was to assess our own results after mesh rectopexy.

PATIENTS AND METHODS

 We reviewed the results in 50 patients on whom posterior abdominal Marlex mesh rectopexy for complete rectal prolapse had been performed. These patients underwent pre- and post-operative anal manometry. Sixteen of them also underwent colon transit time study before and after the operation. They were followed clinically for a median of 5 months.

RESULTS

 Twenty-two of the 38 patients (58%) with preoperatively defective anal control regained full continence. Resting anal canal pressures improved significantly after surgery in all cases (P=0.001), including those who regained full continence (P=0.005). The change in continence in all patients correlated inversely with the preoperative (r=-0.43, P=0.003) and post-operative (r=-0.40, P=0.005) resting anal pressures. The change in resting anal pressures after surgery was significantly better in patients under 40 years of age (mean 19 cmH2 O) than in those 40 years or older (mean 4 cmH2 O) (P=0.01). All four preoperatively incontinent patients regained full continence in the younger group as opposed to only 50% (17/34) in the older group. Colon transit time normalized in three of the four patients with preoperatively slow transit time and five patients with preoperatively normal transit time developed slow transit.

CONCLUSION

 Internal sphincter pressures do improve after mesh rectopexy for rectal prolapse, and the change also correlates with the improvement in continence. Internal sphincter function and continence recover better in younger patients.

SURGERY FOR COMPLETE RECTAL PROLAPSE: A SIMPLIFIED APPROACH

Complete prolapse of rectum (procedentia) is said to occur when the full circumference of the rectal wall is everted through the anus. Numerous techniques have been developed in order to treat procedentia, an uncommon pathology that is managed occasionally by the general surgeon. A simple, safe and effective procedure is recommended for surgeons who treat procedentia recti once in a while. We describe a simple rectopexy procedure which has been used effectively in 38 patients in the last 10 years. In this prospective study we evaluated the results which are comparable to other standard operative techniques in terms of morbidity, anatomic correction and bowel function. This technique is based on sound scientific principles in the aetiopathogenesis of rectal prolapse. This procedure obliterates the abnormally deep cul de sac of rectovesical pouch and supports the anterior rectal wall by suturing it to the bladder base to prevent initiation of sliding herniation of anterior rectal wall, which causes procedentia recti. Posterior dissection fibrosis fixes the posterior rectal wall to the sacrum after healing and restores the normal posterior curve of rectal canal and corrects the pathogenic straightening of rectum which promotes prolapse. Minimal mobilization of rectum is done and lateral ligaments are not dissected hence all attendant complications e.g. impotence, urinary incontinence, constipation etc are avoided. Simplicity, effectiveness, safety and non requirement of prosthetic material makes it an ideal operation suitable for a general surgeon working in the periphery.

Abdominal rectovaginopexy: modified technique to treat constipation

PURPOSE

We noted the combination of obstructed defecation or constipation and fecal incontinence, the poor results of abdominal rectopexy for constipation, and the well-known risk of postoperative induction of constipation after rectopexy. We developed a new operation to treat patients with constipation or fecal incontinence (with a concomitant rectocele, internal rectal intussusception, enterocele at dynamic defecography, or all three) or both. This new rectopexy technique avoided dorsolateral mobilization of the rectum and did not endanger the hypogastric nerves and pelvic autonomic nerves. A better effect on constipation compared with rectopexies with dorsolateral mobilization was expected.

METHODS

The results of this new operation, which was called rectovaginopexy, were studied prospectively in a series of 27 patients. Four-year results were obtained. Preoperative and postoperative questionnaires, dynamic defecograms, and anorectal physiology studies were analyzed.

RESULTS

Before the operation 17 patients were constipated, compared with 4 patients one year after rectovaginopexy (76 percent improvement; P = 0.0015) and 5 patients four years after rectovaginopexy (71 percent improvement: P = 0.005), respectively. At one year, fecal incontinence decreased significantly: 15 of 17 patients improved and 9 patients became fully continent (P = 0.0007). Four years after rectovaginopexy the effect on fecal incontinence was no longer significant (P = 0.09). Rectovaginopexy restored anatomy: all (9) enteroceles, all but 1 (17) internal rectal intussusception, and 12 of 20 rectoceles dissolved, and the majority were reduced in size. Rectal sensation for distention was unchanged, and rectal electrosensitivity improved (P = 0.04).

CONCLUSIONS

Rectovaginopexy provides significant one-year improvement of both constipation and fecal incontinence. The positive effect on constipation did not deteriorate with time, in contrast to the effect on fecal incontinence.