Digital assessment of lower rectum fixity in rectal prolapse (DALR): a simple clinical anatomical test to determine the most suitable approach (abdominal versus perineal) for repair

OUP accepted manuscript

Background

External rectal prolapse (ERP) is a debilitating condition in which surgery plays an important role. The aim of this study was to evaluate the outcomes of abdominal approaches (AA) and perineal approaches (PA) to ERP.

Methods

This was a PRISMA-compliant systematic review with meta-analysis. Studies published between 1990 and 2021 were retrieved. The primary endpoint was recurrence at the last available follow-up. Secondary endpoints included factors associated with recurrence and function. All studies were assessed for bias using the Newcastle–Ottawa Scale and Cochrane tool.

Results

Fifteen studies involving 1611 patients (AA = 817; PA = 794) treated for ERP were included, three of which were randomized controlled trials (RCTs; 114 patients (AA = 54; PA = 60)). Duration of follow-up ranged from 12 to 82 months. Recurrence in non-randomized studies was 7.7 per cent in AA versus 20.1 per cent in PA (odds ratio (OR) 0.29, 95 per cent confidence interval (c.i.) 0.17 to 0.50; P < 0.001, I² = 45 per cent). In RCTs, there was no significant difference (9.8 per cent versus 16.3 per cent, AA versus PA (OR 0.82, 95 per cent c.i. 0.29 to 2.37; P = 0.72, I² = 0.0 per cent)). Age at surgery and duration of follow-up were risk factors for recurrence. Following AA, the recurrence rates were 10.1 per cent and 6.2 per cent in patients aged 65 years and older and less than 65 years of age, respectively (effect size [e.s.] 7.7, 95 per cent c.i. 4.5 to 11.5). Following PA, rates were 27 per cent and 16.3 per cent (e.s. 20.1, 95 per cent c.i. 13 to 28.2). Extending follow-up to at least 40 months increased the likelihood of recurrence. The median duration of hospital stay was 4.9 days after PA versus 7.2 days after AA. Overall, incontinence was less likely after AA (OR 0.32), but constipation occurred more frequently (OR 1.68). Most studies were retrospective, and several outcomes from RCTs were not consistent with those observed in non-RCTs.

Conclusion

The overall risk of recurrence of ERP appears to be higher with PA versus AA. Incontinence is less frequent after AA but at the cost of increased constipation. Age at surgery and duration of follow-up are associated with increased risk of recurrence, which warrants adequate reporting of future studies on this topic.

Altemeier's procedure for complete rectal prolapse; outcome and function in 43 consecutive female patients

Background

The aim of this retrospective study was to evaluate morbidity, mortality, postoperative function and recurrences in patients treated by Altemeier’s rectosigmoidectomy for complete rectal prolapse in a referral center for pelvic floor functional disorders.

Methods

Peri-operative data on 43 consecutive female patients were reviewed. At follow-up any change in pelvic floor function and recurrences were determined. Thirty four patients were assessed at a median interval of 49 (2–135) months, six being deceased for reason not related to the prolapse and three lost to follow-up.

Results

Post-operative complications at 30 days occurred in 18 patients (38%). Major complication occurred in only one patient that was pneumonia with lung failure. Major complications were not related to the ASA score, BMI or age [average age 76.4]. There was no post-operative mortality at 30 days.

At long-term follow-up functional results demonstrate a statistically significant decrease in the Obstructive Defecation Syndrome (ODS) score, but no statistically significant changes in the Vaizey score, the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) score and the urinary retention score. ODS score decreased with respect to levatorplasty and the change was statistically significant instead of Vaizey score in which were not.

At the same follow-up there were 12 (35%) cases of recurrence with an estimated risk at 48 months of 40%. There were no statistically significant differences between patients with and without recurrence regarding age (p = 0.188), BMI (p = 0.864), ASA score (p = 0.433), previously repaired prolapse (p = 0.398), previous hysterectomy (p = 0.705), length of resected bowel (p = 0.126), and levatorplasty (p = 0.304). Patient satisfaction showed a mean of 8.8 and 6.4 respectively in patients without and with recurrences (p = 0.012).

Conclusions

Altemeier’s procedure had in our series low complications rate and no mortality. It offered improved evacuation in constipated patients while didn’t improve fecal and urinary continence. Recurrence of prolapse was 40% at four years.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0463-7) contains supplementary material, which is available to authorized users.

Neglected intussusception presenting as transanal prolapse of small bowel

Although transanal prolapse of intussusception in infants is well recognized, it is rarely reported and confusion with rectal prolapse often results in delayed diagnosis and treatment. This report highlights the problems of delayed diagnosis and the morbidity and mortality associated with this condition. The authors report a case of 9 mo old boy who presented with prolapsing small bowel mimicking rectal prolapse.

Common transabdominal surgical options for rectal prolapse

Rectal prolapse is a troublesome anorectal disorder. Surgical procedures for rectal prolapse contain transabdominal and transperineal approaches. There are hundreds of transabdominal procedures currently available for treatment of the disease, such as Ripstein procedure, Wells procedure, Orr procedure, Nigro procedure, anterior resection, Frykman-Goldberg procedure, and Roscoe Graham procedure. Laparoscopic repair represents the latest advance in surgical treatment of rectal prolapse. As each procedure has its strength and weakness, personalized selection of appropriate procedure can greatly improve surgical outcome. Individualized diagnosis and treatment plan may represent a new direction for transabdominal surgical treatment of rectal prolapse.

Rectosigmoid Intussusception through the Anus Mimicking Rectal Prolapse

Intussusception of the colon usually occurs in infants and children. Although rectal prolapse is not uncommon, presentation of more proximal segments of large bowel through the anus is extremely rare. We report two cases of rectosigmoid intussusception in which sigmoid colon intussusception was diagnosed as rectal prolapse preoperatively.