Complete Rectal Prolapse Evolution of Management and Results Do-Sun Kim, M.D., Charles B. S. Tsang, M.D., F.R.C.S.(Edinb.), F.R.C.S.(Glasg.), W. Douglas Wong, M.D., F.R.C.S.(C), Ann C. Lowry, M.D., Stanley M. Goldberg, M.D., Hon.F.R.A.C.S., Hon.F.R.C.S.(Engl.), Hon.A.F.C.(Fr.), Hon.F.R.C.P.S.(Glasg.), Hon.R.S.M.(Engl.), Robert D. Madoff, M.D. From the Division of Colon a n d Rectal Surgery, Department of Surgery, University of Minnesota School of Medicine, Minneapolis, Minnesota Optional treatment for complete rectal prolapse remains controversial. PURPOSE: We reviewed our experience over a 19-year period to assess trends in choice of operation, recurrence rates, and functional results. METHODS: We identified 372 patients who underwent surgery for complete rectal prolapse between 1976 and 1994. Charts were reviewed and follow-up (median, 64; range, 12-231 months) was obtained by mailed questionnaire (149 patients; 40 percent) and telephone interview (35 patients; 9 percent). Functional results were obtained from 184 responders (49 percent). RESULTS: Median age of patients was 64 (11-100) years, and females outnumbered males by nine to one. One-hundred and eighty-eight patients (51 percent) were lost to follow-up; 183 patients (49 percent) underwent perineal rectosigmoidectomy, and 161 patients (43 percent) underwent abdominal rectopexy with bowel resection. The percentage of patients who underwent perineat rectosigmoidectomy increased from 22 percent in the first five years of the study to 79 percent in the most recent five years. Patients undergoing perineal rectosigmoidectomy were more likely to have associated medical problems as compared with patients undergoing abdominal rectopexy (61 vs. 30 percent, P = 0.00001). There was no significant difference in morbidity, with 14 percent for perineal rectosigmoidectomy vs. 20 percent for abdominal rectopexy. Abdominal procedures were associated with a longer length of stay as compared with perineal rectosigmoidectomy (8 vs. 5 days, P = 0.001). Perineal procedures, however, had a higher recurrence rate (16 vs. 5 percent, P = 0.002). Functional improvement was not sigllificantly different, and most patients were satisfied with treatment and outcome. CONCLUSIONS: We conclude that abdominal rectopexy with bowel resection is associated with low recurrence rates. Pefineal rectosigmoidectomy provides lower morbidity and shorter length of stay, but recurrence rates are much higher. Despite this, perineal rectosigmoidectomy has appeal as a lesser procedure for elderly patients or those patients in the high surgical risk category. For younger patients, the benefits of perineal rectosigmoidectomy being a lesser procedure must be weighed against a higher recurrence rate. [Key words: Rectal prolapse; Recurrence; Abdominal rectopexy; Perineai rectosigmoidectomy; Fecal incontinence; Constipation; Patient satisfaction]
Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996, and at the Tripartite Meeting, London, United Kingdom, July 8 to 10, 1996. Address reprint requests to Dr. Madoff: 2550 University Avenue West, Suite 313N, St. Paul, Minnesota 55114.
Kim D-S, Tsang CBS, Wong WD, Lowry AC, Goldberg SM, Madoff RD. Complete rectal prolapse: evolution of management and results. Dis Colon Rectum 1999;42:460-469. o m p l e t e rectal p r o l a p s e is a socially d i s a b l i n g c o n d i t i o n afflicting b o t h the v e r y y o u n g a n d the old. Early E g y p t i a n a n d G r e e k writings h a v e d e s c r i b e d the u s e o f h o n e y s u p p o s i t o r i e s a n d gravity to r e d u c e the p r o l a p s e d b o w e l . M o d e r n m a n a g e m e n t has since e v o l v e d with a b e t t e r u n d e r s t a n d i n g o f the e t i o l o g y a n d p a t h o p h y s i o l o g y o f the disease. The m y r i a d o f m e t h o d s available to correct t h e u n d e r l y i n g a n a t o m i c defects in c o m p l e t e rectal p r o l a p s e p o s e s a p e r p l e x i n g q u e s t i o n for the s u r g e o n , i.e., the c h o i c e
C
o f a n i d e a l o p e r a t i o n . A m o n g factors to c o n s i d e r in the s e l e c t i o n o f a t r e a t m e n t o p t i o n are the a g e a n d h e a l t h o f a patient, functional status, a n d the benefits vs. t h e d i s a d v a n t a g e s o f a surgical t e c h n i q u e . C o n v e n t i o n a l w i s d o m has h e l d that a b d o m i n a l p r o c e d u r e s y i e l d b e t t e r results in terms o f success in restoring anatomy" a n d function, w h e r e a s p e r i n e a l p r o c e d u r e s w i t h h i g h e r rates o f r e c u r r e n c e a n d functional a b n o r m a l i t y are b e s t r e s e r v e d for patients o f p o o r h e a l t h a n d h i g h surgical risk. H o w e v e r , p r o s p e c tive r a n d o m i z e d trials c o m p a r i n g t h e s e t w o p r o c e d u r e s h a v e b e e n few, a n d r e c e n t series o n p e r i n e a l r e c t o s i g m o i d e c t o m y h a v e r e p o r t e d results c o m p a r a b l e w i t h t h o s e s e e n f o l l o w i n g a b d o m i n a l repair. >4 At the University o f Minnesota, t h e r e has b e e n a n o t i c e a b l e t r e n d b a s e d in part o n t h e s e claims t o w a r d p e r f o r m i n g m o r e p e r i n e a l p r o c e d u r e s o v e r the last d e c a d e . T h e a i m o f this r e t r o s p e c t i v e s t u d y is to assess the e v o l u t i o n o f m a n a g e m e n t o f c o m p l e t e rectal p r o l a p s e in o u r c e n t e r o v e r the last t w o d e c a d e s a n d to e v a l u a t e a n y t r e n d s a n d results.
PATIENTS
AND
METHODS
A r e t r o s p e c t i v e r e v i e w w a s c o n d u c t e d o n office charts o f all patients t r e a t e d for c o m p l e t e rectal p r o 460
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lapse between January 1976 and December 1994. Complete rectal prolapse was defined as full-thickness protrusion of the rectal wall through the anal orifice. Patients with internal prolapse and mucosal prolapse were excluded. Age at time of surgery, gender, presenting symptoms, associated medical problems, type of procedure, complications, mortality, length of hospital stay, and bowel and sphincter function preoperatively were recorded. A postal questionnaire was also mailed to all patients to assess their sphincter and bowel function postoperatively as well overall satisfaction with treatment. Patients were also asked whether their prolapse symptoms recurred, and if so, w h e n and whether further treatments have been sought and rendered. Constipation in our study was defined as less than three bowel movements a week, difficulty emptying requiring straining, or dependent use of laxatives or enemas. Fecal incontinence was defined as inability to control liquid or solid stools. A recurrence was defined as full-thickness protrusion of the neorectal bowel wall. All recurrences were confirmed by physical examination by the attending staff surgeon and documented in the clinic charts. For nonresponders to the postal questionnaire, an attempt was made to contact them by telephone; w h e n possible, an interview was conducted by one of the authors (DSK) w h o had not been involved in any of the operations. Preoperative assessment of sphincter function was performed by anal manometry, using a four-channel water perfused catheter (Amdorfer Medical Specialties, Inc., Greendale, WI; external diameter, 4 mm) connected to a pressure recorder (Narco Bio Systems, Houston, TX; subsequently, Synetics, Minneapolis, MN). A station pull-through technique was used at 1-cm intervals commencing 6 cm from the anal verge. 5 Preoperative constipation was investigated by defecating proctography to exclude outlet obstruction and transit marker studies w h e n slow colonic motility was suspected. All symptoms of diarrhea were also evaluated by sigmoidoscopy. Our standard abdominal procedure for complete rectal prolapse is suture rectopexy and sigmoid resection.< 7 The rectum is mobilized anteriorly and posteriorly down to the pelvic floor. Suture rectopexy is then performed using nonabsorbable sutures to fix the lateral stalks to the presacral fascia. No slings or mesh were used, Redundant sigmoid colon is resected, and the anastomosis is completed at the level just below the pelvic brim. When constipation owing to slow colonic transit is identified, a subtotal colec-
461
tomy is performed at the time of rectopexy or as a secondary procedure if anal sphincter function is norreal. 8 The perineal procedure favored by our group is perineal rectosigmoidectomy, popularized by Altemeier et al. 9 and others. ~°, n In some patients, this was augmented with an anterior as well as a posterior levatoroplasty. 4 Patients undergoing abdominal rectopexy with or without colonic resection were categorized into the abdominal procedure group, and patients undergoing perineal rectosigmoidectomy were categorized into the perineal procedure group. Statistical analysis of categorical data was performed using a computer statistical package, SPSS® for Windows TM (SPSS Inc., Chicago, IL). Chi-squared values were calculated using maximum likelihood ratios. Where cell numbers were small, Fisher's exact test was used. Log-rank analysis of relapse-free survival curves was performed. A P value of <0.05 was considered statistically significant.
RESULTS A total of 372 patients who had surgery for complete rectal prolapse were identified. Median age of patients in our study was 64 (range, 11-100) years. Females outnumbered males by a ratio of 9:1 and were generally older (median age, 65 years) than men (median age, 44 years). Patients who underwent perineal procedures were generally older (median, 75; range, 14-100 years) than patients who underwent abdominal rectopexy (median, 52; range, 11-85 years; P 0.001). A total of 183 (49 percen0 of our patients underwent perineal rectosigmoidectomy, and 176 (47 percenO underwent abdominal rectopexy, most (161 patients, 91 percenO with concomitant colon resection. One hundred and forty-four had sigmoid colectomy, 15 patients had subtotal colectomy, and 2 patients had an extended left hemicolectomy. Other procedures performed include I)elorme's operation (11 patients) and anterior resection (2 patients). Over the last ten years, there has been a rise in the number of perineal procedures and a corresponding decline in the nmnber of abdominal procedures (Fig. 1). Twenty patients (5 percent) had a previous operation for their rectal prolapse performed elsewhere, and 92 patients (25 percenO had previous anorectal surgery to treat other symptoms. Mean follow-up in the group of patients w h o underwent abdominal rectopexy was 98 (range, 16-231; standard deviation, 50) months. This was significantly =
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KIM ETAL
longer than the mean follow-up of 47 months in patients who underwent perineal rectosigmoidectomy (range, 12-165; standard deviation, 32 months; P < 0.0001). Fifty-two (30 percent) of the 176 patients who underwent abdominal rectopexy had associated medical problems as opposed to 112 (61 percent) of the 183 patients in the perineal procedure group. This difference is statistically significant (P = 0.000001; Fig. 2). One-hundred and fourteen (34 percent) of the 336 female patients had a history of previous hysterectomy, and 64 (19 percent) of the 372 patients had associated psychiatric illness. Morbidity was similar between abdominal and pe> ineal procedures (35 of 176 (20 percent) vs. 26 of 183 (14 percent), P = not significant (NS)). The most
Dis Colon Rectum, April 1999
common complication following abdominal rectopexy was small bowel obstruction in 21 patients, which was successfully managed conservatively in 15 patients but required surgery in 6 patients (Table 1). Perineal procedures had more anastomotic complications (Table 2). There was one death in our series. Mean length of hospital stay was eight days for abdominal procedures and five days for perineal procedures (P = 0.001). Mailed questionnaires were returned by 149 (40 percent) patients, and telephone interviews were conducted in a further 35 (9 percent) patients, giving a total response rate of 49 percent from which postoperative functional data were gathered. One hundred eighty-eight patients (51 percent) lost to follow-up had either died or moved without leaving a forward-
35 30
-* -Abdominal
~ 2O ~
15
0
10
o
s
Z
-~
Perineal
0
YEAR
Figure 1. Trend in the number of abdominal and perineal procedures performed 40 -,
f r o m 1 9 7 6 until 1 9 9 4 .
38
35
r~Abdominal a Perineal
30 25
I
21
20
17 14
15
11
9
10 5
CVS
CNS
Arthritis
COPD
Diabetes
Other
Figure 2. Associated medical problems in patients undergoing abdominal rectope×y and perineal rectosigmoidectomy. C V S = cardiovascular system; C N S = central nervous system; C O P D = chronic obstructive pulmonary disease.
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SURGICAL ~EREATMENTFOR RECTALPROLAPSE
ing address or contact telephone number. In these patients, postoperative functional data could not be obtained, but final outcome at time of last clinic visit was used in relapse free survival analysis. Measured endpoints were censored at the respective time intervals during the analysis of these patients. Recurrence rate was 5 percent (9 of 176) in the abdominal rectopexy group v s . 16 percent (29 of 183) for the perineal rectosigmoidectomy group ( P = 0.002). Results stratified by age are shown in Table 3. Although recurrence rates in the middle age group (40-64 years) were similar for both operations, recurrences occurred more frequently following perineal rectosigmoidectomy in the young (<40 years ( P = 0.02)) or older (>65 years ( P = 0.07)) age groups. Table 1. Complications Related to Abdominal Rectopexy (176 Patients) Type of Complication
No. of Events
Small bowel obstruction Pulmonary incisional hernia Cardiac Wound infection Sexual dysfunction Anastomotic stricture Others Total
21 3 3 2 2 2 2 4 39 events in 35 patients
Table 2. Complications Related to Perineal Rectosigmoidectomy (183 Patients) Type of Complication Urinary Cardiac Anastomotic leakage Pulmonary Anastomotic bleeding Anastomotic stricture Acute confusion Others Total
No. of Events 6 4 3 3 2 2 2 7 29 events in 26 patients
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Relapse-free survival was analyzed by a Kaplan-Meier survival plot as shown in Figure 3. For perineal rectosigmoidectomy, recurrences occurred as early as within the first year after surgery, and most occurred within three years. For abdominal rectopexy, recurrences are fewer and they occur mostly between one and three years from time of surgery. One patient developed a recurrence 14 years following first surgery. Overall, perineat rectosigmoidectomy had a lower recurrence free survival when compared with abdominal rectopexy. Log-rank analysis comparing the two recurrence free survival curves showed a statistically significant difference (P = 0,0001). Preoperative constipation was present in 99 of 361 patients (27 percent). Fecal incontinence was present preoperatively in 128 of 343 patients (37 percent). Sixty-five patients (19 percent) complained of incontinence to liqu{d stools, and 63 patients (18 percent) complained of incontinence to solid stools. Nineteen patients (6 percent) were incontinent to gas. Postoperative data on function pertaining to constipation and incontinence were available only from patients w h o responded by questionnaire or agreed to a telephone interview. Of these 184 responders, 39 patients were excluded from the analysis because they had had a repeat procedure or a previous procedure performed elsewhere. Postoperative bowel function was evaluated in this group of 145 patients, 82 (57 percenO of w h o m had symptoms of incontinence preoperatively. Forty-four of these 82 patients had abdominal rectopexy, and 38 patients underwent perineal rectosigmoidectomy. Improvement in continence was seen in 24 of 44 patients (55 percent) w h o had abdominal rectopexy and 20 of 38 patients (53 percent) w h o had perineal rec~osigmoidectomy. Eighty-six patients had symptoms of constipation preoperatively. Improvement in constipation was seen in 23 of 53 patients (43 percent) w h o had abdominal rectopexy vs. 20 of 33 patients (61 percent) w h o had perineal rectosigmoidectomy ( P = NS). Overall patient satisfaction with treatment was
Table 3. Recurrence Rates by Type of Procedure and Age Age
Abdominal Rectopexy
Perineal Rectosigmoidectomy
<40 years 3.9 (2/51) 26.7 (4/15) 40-64 years 6.0 (5/84) 6.3 (2/32) >65 years 4.9 (2/41) 16.9 (23/136) Overall 5.1 (9/176) 15.8 (29/183) Figures are percentages and (proportion of cases) unless otherwise specified.
P Value 0.02 1.00 0.07 0.002
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KIM E T A L
Dis Colon Rectum, April 1999
Survival Functions 1.0
4
1.1-
t-lt-t+-l+-+t~+
%..
PROCEDURE
113
Peri'~_.al
I:IC .8 E
-I-
l:~m-censored Abdomilal
+ 0
24 I2
48 36
72 60
96 84
Abdom-cen sored
120 144 168 192 216 240 108 132 156 180 204 228
Time(months) Figure 3. Recurrence-free survival plots comparing abdominal rectopexy vs. perineal rectosigmoidectomy. Log rank, chi-squared = 15.58; df = 1" P = 0.0001.
comparable in both groups. Eighty-four percent (57/ 68) of patients who underwent abdominal rectopexy were satisfied with the treatment vs. 76 percent (47/ 62) of patients who underwent perineal sigmoidectomy (P = NS).
DISCUSSION The choice of an ideal operation for complete rectal prolapse remains a perplexing problem for the surgeon. Factors that influence the choice of procedure include the age and health of the patient, reported success rates, and complications of a procedure. Abdominal procedures have traditionally b e e n associated with a lower recurrence rate and better functional outcome. Previous studies have reported recurrence rates of 2 to 9 percent. 12' 13 This procedure remains popular for younger patients with low operative risk. Suture rectopexy has been shown to give as good results as rectopexy using foreign materials such as Marlex ® mesh (C.R. Bard Inc., Billerica, MA) or Ivalon ® sponge (Downs Surgical, Sheffield, U.K.), without the potential risk of septic complications related to the sling. Rectopexy is often combined with a resection of the redundant sigmoid colon. The benefits of improved bowel function following colon re-
section outweigh the small risk of an anastomotic leak. 14 The demographic characteristics of patients in this study were similar to that reported in other series. 12'15'16 Females predominate over males by a ratio of nine to one. Female patients were generally older than males, with mean ages of 65 and 44, respectively. Perineal rectosigmoidectomy, first described by Mikulicz in 188917 and popularized by Altemeier, 9 remains a popular procedure for elderly and high surgical risk patients because it is technically easy to perform with low morbidity. 1,4, ls-21 The technique involves mobilizing and resecting excess redundant rectosigmoid via a perineal approach. The anastomosis is either hand-sutured 9 or stapled. 1°, 1~ Levatoroplasty may be performed anteriorly and/or posteriorly. 22 Although Altemeier documented a recurrence of only 2.8 percent, subsequent series reported recurrence rates as high as 50 to 60 percent. 23, 24 Even though the recurrence rate is much higher than that reported for abdominal rectopexy, most proponents argue that a repeat perineal procedure can be performed safely if necessary. Furthermore, recent reports on perineal rectosigmoidectomy have been favorable. >3 Our earlier experience reported by
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SURGICALTREATMENTFOR RECTALPROLAPSE
Williams showed a recurrence rate of 10 percent. 4 Based on these claims, there has been a noticeable trend at the University of Minnesota and its affiliated hospitals toward performing more perineal procedures. Our current study reviews this trend and the results of management. Abdominal rectopexy with sigmoid resection (Frykman-Goldberg procedure) remains the abdominal procedure of choice at our institution. Technical features include complete rectal mobilization, suture rectopexy without foreign material, and resection of redundant colon with intra-abdominal anastomosis, s, 25 Patients in this group were younger and healthier (median age, 52 years; associated medical problems in 30 percent) as compared with patients undergoing perineal procedures (median age, 75 years; associated medical problems in 61 percent; P < 0.001). The recurrence rate of 5 percent for abdominal rectopexy in this study compares well with previous reported rates of 2 to 9 percent. 12' 13 This nonrandomized series documents a significantly higher recurrence rate for perineal rectosigmoidectomy than resection rectopexy. Broken down by age, recurrence rates are remarkably similar for patients aged 40 to 64. On the other hand, patients <40 or >65 years had strikingly higher recurrence rates following perineal rectosigmoidectomy. Although this finding at first glance suggests the superiority of resection rectopexy for these age groups, this conclusion must be reached with caution. In general, we believe that the selection bias would tend to place the bulk of patients at highest risk for recurrence in the perineal rectosigmoidectomy group. In addition, specific circumstances in both the young and older patient groups may dictate the choice of the perineal operation despite the higher recurrence rate. Thus, a perineal repair may be preferable for young men who wish to avoid the risk of nerve injury and sexual dysfunction following a transabdominopelvic dissection. Profoundly disturbed, institutionalized psychiatric patients may also be better served by the more expeditious and less painful perineal approach. In the older age group, patients with extreme age, generalized infirmity, or specific associated medical illness all stand to benefit from the potentially less morbid perineal approach, notwithstanding the higher risk of recurrence. Success of treatment should not only be measured in terms of restoration of anatomy but also by improving the bowel function of patients. From previous retrospective studies, it is known that constipation can
465
be worsened after surgery for rectal prolapse. 26 Constriction from a circumferential mesh, denervation injury from division of the lateral stalks, 27, 28 and presence of a redundant sigmoid loop with impaired motility have been postulated to contribute to this problem. In our series of patients undergoing abdominal rectopexy with sigmoid resection, 43 percent of patients with complaints of preoperative constipation reported an improvement postoperatively. Perineal rectosigmoidectomy seemed to improve bowel function more often with 61 percent reporting an improvement in constipation symptoms. These differences, however, were not statistically significant. Fecal incontinence is another functional problem that may persist postoperatively. Sphincter function has been shown to recover with time postoperatively owing to recovery of the internal 29 or both internal and external anal sphincters. 5, 14 The addition of levatoroplasty to perineal rectosigmoidectomy has been shown to significantly improve functional outcome, 4 though the removal of the rectal reservoir necessary for this operation may tend to impair control. Improvement in anal sensation and decreased rectal sensory threshold following abdominal rectopexy may also help restore continence. 30 Our results showed 55 percent improvement in continence in the abdominal rectopexy group v s . 53 percent improvement in the perineat rectosigmoidectomy group (P = NS). Unfortunately, our low follow-up rate of 49 percent precludes any dogmatic conclusions with regard to functional outcome between the two procedures.
CONCLUSION Abdominal rectopexy with bowel resection is associated with a low recurrence rate and fair restoration of function in patients with complete rectal prolapse. Perineal rectosigmoidectomy provides lower morbidity and shorter length of stay -with similar improvement in function, but recurrence rates are much higher. Despite this, perineat rectosigmoidectomy has appeal as a lesser procedure for elderly patient.s or for those at high surgical risk as a result of comorbid disease. For younger patients, the benefits of perineal rectosigmoidectomy being a lesser procedure must be weighed against a higher recurrence rate. These conflicting considerations preclude a simple or universal answer to the question of the "optimal" operation for rectal prolapse. This decision often remains difficult
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and is best tailored to the individual patient and surgeon. 17. 18.
REFERENCES 1. Johansen OB, Wexner SD, Daniel N, Nogueras JJ, Jagelman DG. Perineat rectosigmoidectomy in the elderly. Dis Colon Rectum 1993;36:767-72. 2. Ramanujam PS, Venkatesh KS. Perineal excision of rectal prolapse with posterior levator ani repair in elderly high-risk patients. Dis Colon Rectum 1988;31:704-6. 3. Finlay IG, Aitchison M. Perineal excision of the rectum for prolapse in the elderly. Br J Surg 1991;78:687-9. 4. Wiltiams JG, Rothenberger DA, Madoff RD, Goldberg SM. Treatment of rectal prolapse in the elderly by pe> ineal rectosigmoidectomy. DiS Colon Rectum t992;35: 830-4. 5. Williams JG, Wong WD, Jensen LL, Rothen.berger DA, Goldberg SM. Incontinence and rectal prolapse: a prospective manometric study. Dis Colon Rectum 1991;34: 209-16. 6. Frykman, HM. Abdominal rectopexy and primary sigmold resection for rectal procidentia. Am J Surg 1955; 90:780-9. 7. Frykman HM, Goldberg SM. The surgical treatment of rectal procidentia. Surg Gynecol Obstet 1969;129: 1225-30. 8. Madoff RD, Williams JG, Wong WD, Rothenberger DA, Goldberg SM. Long-term functional results of colon resection and rectopexy for overt rectal prolapse. Am J Gastroenterol 1992;87:101-4. 9. AltemeierWA, Culbertson WR, Schowengerdt C, HuntJ. Nineteen years' experience with the one-stage perineal repair of rectal prolapse. Ann Surg 1971;173:993-1006. 10. Bennett BH, Geelhoed GW. A stapler modification of the altemeier procedure for rectal prolapse. Experimental and clinical evaluation. Am Surg 1985;51:116-20. 11. Vermeulen FD, Nivatvongs S, Fang DT, Balcos EG, Goldberg SM. A technique for perineal rectosigmoidectomy using autosuture devices. Surg Gynecol Obstet 1983;156:84-6. 12. Watts JD, Rothenberger DA, Buls JG, Goldberg SM, Nivatvongs S. The management of procidentia: 30 years' experience. Dis Colon Rectum 1985;28:96-102. 13. Husa A, Sainio P, yon Smitten K. Abdominal rectopexy and sigmoid resection (Frykman-Goldberg operation) for rectal prolapse. Acta Chir Scand 1988;154:221-4. 14. Huber FF, Stein H, Siewert JR. Functional results after treatment of rectal prolapse with rectopexy and sigmoid resection. World J Surg 1995;19:138-43. 15. Mann C. Rectal prolapse. In: Morson BC, Heinemann W, eds. Diseases of the colon, rectum and anus. London: Medical Books, 1969:238-50. 16. Kupfer CA, Goligher JC. One hundred consecutive
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Dis Colon Rectum, April 1999 cases of complete prolapse of the rectum treated by operation. Br J Surg 1970;57:482-7. Mikulicz J. Zur operativen betiandlung des prolapsus recti et coti invaginati. Arch Klin Chit 1889;38:74-97. Gopal KA, Amshel AL, Shonberg IL, Eftaiha M, Rectal procidentia in elderly and debilitated patients. Experience with the Altemeier procedure. Dis Colon Rectum 1984;27:376-81. Oliver GC, Vachon D, Eisenstat TE, Rubin RJ, Salvati EP. Delorme's procedure for complete rectal prolapse in severely debilitated patients. An analysis of 41 cases. Dis Colon Rectum 1994;37:461-7. Ramanujam PS, Venkatesh KT, Fietz MJ. Perineal excision of rectal procidentia in elderly high-risk patients. A ten-year experience. Dis Colon Rectum 1994;37: 1027-30. Thome MC, Polglase AL. Perineai proctectomy for rectal prolapse in elderly and debilitated patients. Aust N Z J Surg 1992;62:791-4. Prasad ML, Pearl RK, Abcarian H, Orsay CP, Nelson RL. Perineal proctectomy, posterior rectopexy, and postanal levator repair for the treatment of rectal prolapse. Dis Colon Rectum 1986;29:547-52. Friedman R, Muggia-Sulam M, Freund HR. Experience with the one-stage perineal repair of rectal prolapse. Dis Colon Rectum 1983;26:789-91. Hughes ESR. Discussion on rectal prolapse. Proc R Soc Med 1949;42:1007-11. Frykman HM, Goldberg SM. The surgical treatment of rectal procidentia. Surg Gynecol Obstet 1969;129:1225, Allen-Mersh TG, Turner MJ, Mann CV. Effect of abdominal Ivalon rectopexy on bowel habit and rectal wall. Dis Colon Rectum 1990;33:550-3. Speakman CT, Madden MV, Nicholls RJ, Kamm MA. Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study-. BrJ Surg 1991;78:1431-3. Scaglia M, Fasth S, Hallgren T, Nordgren S, Oresland T, Hulten L. Abdorainal rectopexy for rectal prolapse: influence of surgical technique on functional outcome [see comments]. Dis Colon Rectum 1.994;37:805-13. Farouk R, Duthie GS, Bartolo DC, MacGregor AB. Restoration of continence following rectopexy for rectal prolapse and recovery of the internal anal sphincter electromyogram. Br J Surg 1992;79:439-40. Bartolo DC, Duthie GS. The physiological evaluation of operative repair for incontinence and prolapse. Ciba Found Syrup 1990;151:223-45.
Invited Editorial To the Editor--Complete rectal prolapse is profoundly disabling to those w h o suffer it, and not a little perplexing to those w h o treat it. It is not a