Rectal Prolapse in Women-Outcomes of Perineal and Abdominal Approaches

Winnie Mice: A Chronic and Progressive Model of Ulcerative Colitis

Recent trends show a continuous worldwide rise in the incidence of ulcerative colitis (UC), leading to increased interest in its etiology and pathogenesis, which is currently unknown. To gain a better mechanistic understanding of this disease, many mouse models have been developed over the last several years, with variations of dextran sodium sulfate administration representing the most widely employed. The Winnie mouse strain was created through elicited random mutations in Muc2, resulting in a progressive, chronic intestinal inflammation localized to the colon that worsens over time. Moreover, Winnie mice display immunologic and microbiota features that are similar to those that can be found in UC patients. Phenotypically, the presence, albeit rare, of rectal prolapse and other complications impacting quality of life can be observed in Winnie mice, as well as extraintestinal manifestations that are often associated with UC. While Winnie mice are currently less studied compared to other more established models of colitis, much has been discovered in the initial years of its use as a UC-like model. In summary, the use of Winnie mice adds to the growing armamentarium that is required to develop precision-based medicine for its future application in treating complex multifactorial diseases, such as UC.

Rectal Prolapse Surgery: Balancing Effectiveness and Safety in Abdominal and Perineal Approaches

The event in which the entire thickness of the rectum protrudes through the anal canal is called rectal prolapse. This ailment is common in the elderly population and especially in females. It causes some disastrous symptoms, including incontinence to feces and flatus, constipation, and discomfort, because of the weakness in the anorectal junction, making it mandatory for surgical correction. Over time, several surgical techniques have been developed; these are broadly classified into two categories: abdominal and perineal techniques. However, the best approach for surgery that minimizes recurrence while maximizing patient quality of life is still up for debate. A comprehensive review was conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; a systematic search of the PubMed Database was performed to identify studies published between 2000 and 2024 with the keywords ((Rectal Prolapse) AND ("Perineal" OR "Laparotomy")). The inclusion criteria were focused on studies comparing the outcomes between surgical approaches at the abdominal and perineal locations, particularly on the recurrence rate, postoperative complications, and functional outcomes. In total, 21 studies were included in the review: these ranged from retrospective analysis and prospective studies to a multicentric randomized trial. In this review, abdominal approaches, particularly in the form of laparoscopic rectopexy, consistently demonstrated improved results compared to perineal techniques, with a much lower recurrence rate. The rates of mortality and morbidity were also remarkably lower in laparoscopic operations, which were advocated for suitable patients. However, perineal approaches, while still producing higher rates of recurrence, are a valuable alternative for elderly and high-risk patients due to their being relatively less invasive. Laparoscopic rectopexy can be considered a better surgical method for rectal prolapse, as it has a lower recurrence rate and better functional outcomes. In contrast, perineal approaches will have their place in the management of rectal prolapse, given patient selection for patients at high risk with regard to surgery. Future research should be directed toward multicenter trials with long-term outcomes in order further to fine-tune surgery strategy and criteria for patient selection.

Sigmoido-rectal intussusception anastomosis in the Altemeier procedure for complete rectal prolapse: preliminary results of a new technique

Purpose

Our research introduces an innovative surgical approach, combining the Altemeier Procedure with Sigmoido-rectal Intussusception Anastomosis, effectively reducing recurrence, minimizing complications, and improving postoperative anal function in rectal prolapse patients.

Materials and methods

This retrospective study, conducted at tertiary referral hospitals including Shandong University of Traditional Chinese Medicine's Affiliated Hospital, Linyi People's Hospital, and Pingyi People's Hospital, examined data from patients undergoing conventional Altemeier surgery or Altemeier combined with Sigmoido-rectal Intussusception Anastomosis. Analyzing hospitalization and follow-up data from January 2009 to December 2022, the study focused on prolapse recurrence, complications, and anal function as primary outcome indicators across these three study centers.

Results

In the study, both groups had an average follow-up of (12.5 ± 2.41) months, and only two traditional group patients experienced mortality. Recurrence rates significantly differed, with 26.47% in the traditional group and 1.54% in the modified group (P < 0.001). The modified group showed no perioperative anastomotic dehiscence, contrasting with a 13.24% occurrence in the conventional group (P = 0.003). Primary complications in the modified group included anastomotic hemorrhage, with rates of 17.65% and 6.15% in the traditional and modified groups, respectively (P = 0.077). At 12 months postoperatively, both groups improved in anal manometry parameters and the Wexner anal incontinence score. Resting pressure was significantly lower in the traditional group (32.50 ± 1.76 mmHg) than the modified group (33.24 ± 2.06 mmHg) (P = 0.027), while the extrusion pressure was higher in the modified group (64.78 ± 1.55 mmHg) than the traditional group (62.85 ± 2.30 mmHg) (P < 0.001). The Wexner anal incontinence score was significantly lower in the modified group (2.69 ± 1.65) than the traditional group (3.69 ± 1.58, P = 0.001).

Conclusion

This retrospective study affirms that adding Sigmoido-rectal Intussusception Anastomosis to the Altemeier procedure reduces recurrence and complications. While both approaches enhance postoperative anal function in complete rectal prolapse patients, the combined method, particularly with Sigmoido-rectal Intussusception Anastomosis, proves more effective.

Delorme's vs. Altemeier's in the management of rectal procidentia: systematic review and meta-analysis

BACKGROUND

Rectal prolapse is a distressing condition for patients and no consensus exists on optimal surgical management. We compared outcomes of two common perineal operations (Delorme's and Altemeier's) used in the treatment of rectal prolapse.

METHODS

A systematic search of multiple electronic databases was conducted. Peri- and post-operative outcomes following Delorme's and Altemeier's procedures were extracted. Primary outcomes included recurrence rate, anastomotic dehiscence rate and mortality rate. The secondary outcomes were total operative time, volume of blood loss, length of hospital stay and coloanal anastomotic stricture formation. Revman 5.3 was used to perform all statistical analysis.

RESULTS

Ten studies with 605 patients were selected; 286 underwent Altemeier's procedure (standalone), 39 had Altemeier's with plasty (perineoplasty or levatoroplasty), and 280 had Delorme's. Recurrence rate [OR: 0.66; 95% CI [0.44-0.99], P = 0.05] was significantly lower and anastomotic dehiscence [RD: 0.05; 95% CI [0.00-0.09], P = 0.03] was significantly higher in the Altemeier's group. However, sub group analysis of Altemeier's with plasty failed to show significant differences in these outcomes compared with the Delorme's procedure. Length of hospital stay was significantly more following an Altemeier's operation compared with Delorme's [MD: 3.05, 95% CI [0.95 - 5.51], P = 0.004]. No significant difference was found in total operative time, intra-operative blood loss, coloanal anastomotic stricture formation and mortality rates between the two approaches.

CONCLUSIONS

A direct comparison of two common perineal procedures used in the treatment of rectal prolapse demonstrated that the Altemeier's approach was associated with better outcomes. Future, well-designed high quality RCTs with long-term follow up are needed to corroborate our findings.

Abdominal versus perineal approach for external rectal prolapse: systematic review with meta-analysis

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.

Epidemiological trends in surgery for rectal prolapse in England 2001-2012: an adult hospital population-based study

AIM

To analyse trends in admission and surgery for rectal prolapse in adults in England between 2001 and 2012 as well as prolapse reoperation rates.

METHOD

Analysis of data derived from a comparative longitudinal population-based cohort study using Hospital Episode Statistics (HES).

RESULTS

During the study period, a total of 25 238 adults, of median age 73 [interquartile range (IQR: 58-83] years, underwent a total of 29 379 operations for rectal prolapse (mean: 2662 per annum). The female to male ratio of this group of patients was 7:1. Median length of hospital stay was 3 (IQR: 1-7) days with an overall in-hospital mortality rate of 0.9%. Total number of admissions (4950 in 2001/2002 vs 8927 in 2011/2012) and of patients undergoing prolapse surgery (2230 in 2001/2002 vs 2808 in 2011/2012) significantly increased over the study period (P < 0.001 for trends). The overall increase in prolapse surgery (of 33% overall and of 44% for elective procedures) was dwarfed by an increase in popularity of laparoscopic surgery (of 15-fold). Overall prolapse reoperation rate was 12.7%. The lowest recurrence rate was observed for elective open resection (9.1%) but this had the highest mortality (1.9%). Laparoscopic and perineal fixations were also associated with low reoperation rates (< 11%) and the lowest mortality rates, of 0.3%, when these procedures were elective. These data refute a trend towards subspecialization (by surgeon or hospital) during the study period.

CONCLUSION

Admissions for rectal prolapse increased in England between 2001 and 2012, together with increases in rectal prolapse surgery. Surgical decision making has changed over this period and may be reflected in outcome.

Surgical Treatment of Rectal Prolapse in the Laparoscopic Era; A Review of the Literature

Rectal prolapse is associated with debilitating symptoms including the discomfort of prolapsing tissue, mucus discharge, hemorrhage, and defecation disorders of fecal incontinence, constipation, or both. The aim of treatment is to eliminate the prolapse, correct associated bowel function and prevent new onset of bowel dysfunction. Historically, abdominal procedures have been indicated for young fit patients, whereas perineal approaches have been preferred in older frail patients with significant comorbidity. Recently, the laparoscopic procedures with their advantages of less pain, early recovery, and lower morbidity have emerged as an effective tool for the treatment of rectal prolapse. This article aimed to review the current evidence base for laparoscopic procedures and perineal procedures, and to compare the results of various techniques. As a result, laparoscopic procedures showed a relatively low recurrence rate than the perineal procedures with comparable complication rates. Laparoscopic resection rectopexy and laparoscopic ventral mesh rectopexy had a small advantage in the improvement of constipation or the prevention of new-onset constipation compared with other laparoscopic procedures. However, the optimal surgical repair has not been clearly demonstrated because of the significant heterogeneity of available studies. An individualized approach is recommended for every patient, considering age, comorbidity, and the underlying anatomical and functional disorders.

Perineal rectosigmoidectomy for rectal prolapse-the preferred procedure for the unfit elderly patient? 10 years experience from a UK tertiary centre

BACKGROUND

Rectal prolapse is a disease presentation with a prevalence of about 1%, mainly affecting older women. It usually presents with symptoms of rectal mass, rectal bleeding, fecal incontinence or constipation, with patients frequently feeling socially isolated as a result. Perineal rectosigmoidectomy is associated with lesser morbidity and mortality than the abdominal procedure, but with a much higher recurrence rate. Therefore, this technique is mainly suitable for the frail elderly patient. Specific outcomes in an elderly population have been described in only a few studies. We evaluated the morbidity, mortality, recurrence rate and functional results after this procedure related to age.

METHODS

All patients who underwent a perineal rectosigmoidectomy over a 10-year period in two tertiary referral centers were included in the study. American Society of Anesthesiology (ASA) grade, pre- and postoperative symptoms, pathology-reported post-fixation specimen length, length of in-patient stay, 30-day morbidity/mortality, and recurrence were measured.

RESULTS

A total of 45 patients underwent a perineal rectosigmoidectomy. Forty-three (95%) were female, with a median age of 82.0 years (IQR 70.5-86.5), ASA grade III and median follow-up of 20 months (range 8.5-45.5 months). Half of the cohort was over 80 years old. Significant symptomatic relief was achieved, predominantly the resolution of rectal mass (8.9% vs. 60.0% preoperatively), fecal incontinence (15.6% vs. 46.7%) and constipation (4.4% vs. 26.7%). The median length of stay was 6 days, while morbidity occurred in 14 patients (31.1%) and recurrence occurred in 6 patients (13%). There were no deaths within 30 days of the procedure and outcomes were comparable in the < 80 and ≥ 80 age group.

CONCLUSIONS

Perineal rectosigmoidectomy is safe for older patients with greater comorbidities resulting in good functional results and is associated with low morbidity and mortality.

A Modification of the Stapled TransAnal Rectal Resection (STARR) Procedure for Rectal Prolapse

PURPOSE

This study was designed to assess the safety, efficacy, and postoperative outcomes of the modified Stapled TransAnal Rectal Resection (modified STARR) in patients presenting with cases of limited external rectal prolapse.

METHODS

A prospective cohort of patients with mild rectal prolapse undergoing rectal resection with the Tissue-Selecting Technique Stapled TransAnal Rectal Resection Plus (TSTStarr Plus) stapler between February 2014 and September 2016 was reviewed retrospectively.

RESULTS

Twenty-five eligible patients underwent rectal resection with the TSTStarr Plus stapler. The median vertical height of the resected specimen was 5.0 cm (range = 3.1-10 cm) with all cases being confirmed histologically as full-thickness resections. Over a follow-up of 33.6 ± 9.4 months, only 1 case (4%) was encountered with recurrence. The mean postoperative Wexner score was significantly improved when compared with the preoperative scores (preoperative: median = 3, range = 0-20, vs postoperative: median = 2, range = 0-20, respectively; P = .010). The median preoperative Symptom Severity Score and Obstructed Defecation Score were both decreased compared with the postoperative scores ( P = .001).

CONCLUSIONS

Modified STARR in management of mild rectal prolapse appear to be a safe and effective technique. The initial results would encourage a more formal prospective assessment of this technique as part of a randomized trial for the management of mild rectal prolapse.

Perineal resectional procedures for the treatment of complete rectal prolapse: A systematic review of the literature

BACKGROUND AND AIM

Several procedures for the treatment of complete rectal prolapse (CRP) exist. These procedures are performed via the abdominal or perineal approach. Perineal procedures for rectal prolapse involve either resection or suspension and fixation of the rectum. The present review aimed to assess the outcomes of the perineal resectional procedures including Altemeier procedure (AP), Delorme procedure (DP), and perineal stapled prolapse resection (PSR) in the treatment of CRP.

PATIENTS AND METHODS

A systematic search of the current literature for the outcomes of perineal resectional procedures for CRP was conducted. Databases queried included PubMed/MEDLINE, SCOPUS, and Cochrane library. The main outcomes of the review were the rates of recurrence of CRP, improvement in bowel function, and complications.

RESULTS

Thirty-nine studies involving 2647 (2390 females) patients were included in the review. The mean age of patients was 69.1 years. Recurrence of CRP occurred in 16.6% of patients. The median incidences of recurrence were 11.4% for AP, 14.4% for DP, and 13.9% for PSR. Improvement in fecal incontinence occurred in 61.4% of patients after AP, 69% after DP, and 23.5% after PSR. Complications occurred in 13.2% of patients. The median complication rates after AP, DP and PSR were 11.1%, 8.7%, and 11.7%, respectively.

CONCLUSION

Perineal resectional procedures were followed by a relatively high incidence of recurrence, yet an acceptably low complication rate. Definitive conclusions on the superiority of any procedure cannot be reached due to the significant heterogeneity of the studies.