Tech Coloproctol (2006) 10:106–110 DOI 10.1007/s10151-006-0261-6 O R I G I N A L A RT I C L E

J.E. Mansilla • G.C. Bannura • J.P. Contreras • A.E. Barrera • C.L. Melo • D.C. Soto

Lomas-Cooperman technique for rectal prolapse in the elderly patient

Received: 20 June 2005 / Accepted: 10 November 2005 / Published online: 19 June 2006

Abstract Background A variety of surgical procedures is used to correct complete rectal prolapse (RP). We analysed the immediate and long-term results of the Lomas-Cooperman technique in the management of symptomatic RP in elderly patients with severe concomitant diseases. Methods Across a 13-year period, all patients with RP having undergone surgery with this procedure were retrospectively evaluated. The technique consisted in placing a triply folded piece of polypropylene mesh encircling the anal canal through a perineal approach. Results A total of 22 patients (20 female) with a mean age of 84 years (range, 72–93 years) with severe concomitant pathologies were assessed. Four patients were classified as ASA II and 18 as ASA III. Mean Karnofsky score was 50%, ranging between 40% and 60%. All patients were operated on under regional anaesthesia without incidents. Mean operative time was 35 min

(range, 20–60 min) and mean hospital stay was 4.5 days (range, 2–17 days). The most common immediate postoperative complication was urinary tract infection, found in 18% of the cases. Mean follow-up was 32 months (range, 4–84 months). During follow-up, 4 cases (18%) of mesh exteriorisation were detected, requiring mesh trimming at the outpatient clinic. Rectal prolapse recurred in 2 patients; one of them was managed with a new cerclage reaching a satisfactory outcome. Thus, by intention-to-treat basis, the recurrence rate was 4.5%. Constipation was resolved in three out of 4 patients, but in 18% of the cases late faecal impact was recorded. Mean preoperative incontinence score improved from 5.1±0.62 to 3.4±1.61 (p<0.0001) after surgery. Conclusions Anal cerclage with the LomasCooperman technique constitutes a simple and reproducible surgical technique with an acceptable morbidity and recurrence rate in high-risk elderly patients with RP. Key words Rectal prolapse • Anal cerclage

Introduction

J.E. Mansilla • G.C. Bannura () • J.P. Contreras A.E. Barrera • C.L. Melo • D.C. Soto Department of Colorectal Surgery Hospital San Borja Arriaran Faculty of Medicine, University of Chile Santiago, Chile E-mail: [email protected]

Complete rectal prolapse (RP), or procidentia, is a fullthickness protrusion of the rectum through the anal sphincters. It is an uncomfortable and distressing condition that impairs the quality of life, and is commonly associated with faecal incontinence. In adults, the great majority of patients are elderly women [1]. Over 130 procedures have been described for the repair of rectal procidentia, most of them based on the correction of anatomical disorders related to such a pathological condition [1–3]. There is no agreement as to which procedure is the most suitable, but, in general terms, most of the authors favour abdominal procedures for normal-risk patients, while perineal approach techniques are preferred for high-risk elderly patients [1, 4]. Although the latter show poorer long-term results, they can be carried

J.E. Mansilla et al.: Lomas-Cooperman technique for rectal prolapse

out under local or regional anesthesia, thus becoming the most advisable procedure for weakened patients with severe medical conditions and for elderly patients who are unfit for abdominal surgery [1–4]. Among perineal repairs, anal cerclage consists in introducing a ring-shaped foreign material around the anus. This encirclement generates a mechanical support and containment of the procidentia by narrowing the anal opening. Moreover, the technique aims at stimulating fibrosis triggered by the presence of a foreign body in pararectal tissues. First described by Thiersch in 1891 [1, 4], the original technique has undergone many modifications, aimed at improving both recurrence and complication rates [5]. In 1972, Lomas and Cooperman described a new procedure consisting in placing a polypropylene mesh around the anal sphincters which acts as a fixing device [6]. Herein, we report the immediate and long-term results of the Lomas-Cooperman technique for the management of symptomatic RP in frail and elderly patients with severe concurrent diseases.

Patients and methods All consecutive patients with RP operated on by the LomasCooperman technique between January 1991 and December 2003 were included. Morbid history and prior surgical procedures for RP, as well as immediate and long-term complications, were assessed. All patients were classified according to the American Society of Anesthesiology (ASA) classification of physical status [7] and the Karnofsky perfomance status scale [8]. Recurrent RP was defined as full-thickness protrusion of the rectal wall, and mucosal prolapse was defined as the emergence of rectal mucosa through the anus.

a

c

107 To assess the grade of faecal incontinence, the A1-C3, 0–6 Pescatori score [9] was used. Incontinence was considered severe when it occurred weekly or more for liquid and solid faeces (B2-C3; 5 or 6 points). Follow-up was carried out through ambulatory controls at the outpatient clinic or by means of phone interview. Preoperative colon preparation was carried out by giving a liquid diet and a phosphosoda enema in the morning, prior to surgery. Antibiotic prophylaxis included one single dose of 1 g cephazoline and 500 mg metronidazole by intravenous bolus injection, intraoperatively.

Surgical technique A rectangular piece of triply folded polypropylene mesh of 20 cm length and 1.5 cm width was sutured along the edge at 1.5-cm intervals with polypropylene interrupted horizontal mattress sutures (Fig. 1a). The patient was placed in forced lithotomy position while a 1-cm incision was made at the left posterior quadrant, 2 cm from the anal verge. Through this incision, a large-curve Kelly clamp was introduced high enough to reach the upper end of the sphincters, generating a tunnel around the anorectal canal. This forceps was brought out through a similar blunt opening at the upper right quadrant through which the prosthesis was introduced, and then exteriorised through the lower left incision (Fig. 1b). The procedure was then repeated to generate a tunnel around the anus through its right side. Then, the end of the mesh was grasped and its distal end was brought out through the posterior left region. Thus, the mesh was left in the pararectal space encircling the complete anal canal (Fig. 1c). Both limbs of the mesh were sutured together with 2/0 monofilament sutures and a narrow diameter was gauged so as to allow the passage of one finger through the anal opening. The excess mesh was trimmed and the knot was placed deep within the left ischiorectal fossa. Finally, the wound was irrigated with saline

b

d

Fig. 1a-d Lomas-Cooperman technique for rectal prolapse. a A rectangular piece of triply folded polypropylene mesh was prepared with sutures at 1.5cm intervals. b The prosthesis was introduced in the upper right quadrant and brought out through the lower left incision. c The mesh was left in the pararectal space, encircling the complete anal canal. d After the mesh was trimmed and the knot placed deep in the left ischiorectal fossa, the skin was sutured with 3–0 nylon

108 solution and the skin was sutured with 3–0 nylon (Fig. 1d). A stool softener was administered the next day for one or two weeks and the diet was progressed as tolerated.

Statistical analysis The differences between pre- and postoperative incontinence scores were compared using Student’s two-tailed paired t test. A p value <0.05 was considered statistically significant.

Results During the 13-year period, 22 patients with RP underwent anal encirclement with polypropylene mesh. Twenty of them were female and 2 male, with a mean age of 84 years (range, 72–93 years). Fifty-five percent were over 85 years old. Patients had one or more concurrent morbid conditions, including hypertensive cardiopathy in 36% of the cases, senile dementia in 18%, coronary cardiopathy in 9% and stroke sequelae in 9%. Four patients were classified as ASA II and 18 as ASA III. Mean Karnofsky performance status score was 50%, ranging between 40% and 60%. Two patients had a history of hysterectomy for genital prolapse 7 and 12 years prior to the diagnosis of rectal prolapse. Four patients (18%) had been previously operated on at a different care centre for RP using the abdominal approach (three cases of promontory rectopexy without a mesh and one case of Delorme operation). Clinical evolution of RP ranged from 1 month to 10 years. Patients described the sensation of an anal mass in 91% of the cases, soiling in 73%, rectorrhagia in 27% and constipation in 18% of cases. During clinical assessment, rectal exteriorisation upon straining was detected in 19 cases and a marked sphincter hypotonia was recorded in 18 cases. All patients underwent anal cerclage under regional anaesthesia without intraoperative complications, with a mean operative time of 35 min (range, 20–60 min). Mean hospital stay was 4.5 days (range 2–17 days). Immediate postoperative complications are detailed in Table 1. A 90year-old female patient was re-admitted 6 days after surgery with signs of severe perineal infection requiring a loop-sigmoid colostomy and two perineal cleansings under anaesthesia, but the mesh was not removed. The patient’s family refused closure of the colostomy. Mean follow-up was 32 months, ranging between 4 and 84 months. During this period, 9 patients died due to concomitant diseases. One case of mucosal prolapse was successfully managed with rubber band ligation. Recurrence of the prolapse occurred in 2 patients (9%). The first case, diagnosed 3 months after operation, was managed with a new anal encirclement with the same technique, reaching a

J.E. Mansilla et al.: Lomas-Cooperman technique for rectal prolapse Table 1 Immediate postoperative complications in 22 patients who underwent Lomas-Cooperman method for rectal prolapse, and corresponding hospital stay

Urinary infection Faecal impaction Urinary retention Perineal gangrene

Patients, n (%)

Hospital stay, days

4 (18) 1 1(5) 1 1(5) 1 1(5)

3, 3, 7, 17 11 12 60

satisfactory outcome. The other patient recurred after 5 months. This patient was offered the option of a new abdominal approach, and an anterior resection was carried out with a good subsequent evolution. Thus, both recurrences were successfully treated. Considering the intention-to-treat analysis, the global recurrence rate of the Lomas-Cooperman procedure in our series was 4.5% (1 of 22). During follow-up, partial emergence of the mesh through the perineal region in 3 patients and through the vagina in one patient was noted. All these complications resolved with partial trimming of the mesh on an ambulatory basis. Of the 4 patients complaining of constipation preoperatively, 3 were normal after surgery. Constipation developed in 2 patients who has not been constipated prior to surgery and late faecal impaction was recorded in 4 cases (18%). Due to advanced senile dementia in 4 cases, continence was assessed in 18 patients. Preoperative incontinence score (mean±SEM) improved from 5.1±0.62 to 3.4±1.61 (95% CI, 1.19 to 2.35; Student’s t=6.47; SD=17; p<0.0001) after surgery. Of the 18 patients with faecal incontinence prior to surgery, two recovered full continence, 8 improved and 8 remained unchanged. Overall, continence showed a significant improvement in 55% of the patients.

Discussion Surgical therapy of rectal prolapse (RP) must be selected according to the patient, taking into account a variety of factors related to age, concurrent pathologies, and the patient’s general and nutritional conditions [3]. Although there is no agreement concerning the selection of the best procedure, there is a clear preference for abdominal procedures for normal-risk patients. However, surgical procedures using the perineal approach are safer for the elderly and for patients with severe co-morbid conditions. Among other advantages, they can be performed under regional or local anaesthesia with shorter operative time. Moreover, both the postoperative hospital stay and the overall convalescence period are generally shorter for procedures using the perineal approach [1].

J.E. Mansilla et al.: Lomas-Cooperman technique for rectal prolapse

Resective techniques (perineal rectosigmoidectomy or Alteimeier procedure) [3–5, 10, 11], rectal plication through the perineal approach (Delorme procedure) [2, 3–5, 12] and the recently described helicoidal suture of the mucosa [13] stand out among perineal approaches. Nevertheless, the heterogeneity of series precludes any objective comparison between the different procedures. However, these procedures are technically more complex, morbidity is not negligible (up to 60%) and their recurrence rate is 16%–30%, depending mostly on the followup period. In general, follow-up is short because patients are very old and of high-risk, thus seldom exceeding a 3year survival [1–5, 12–14]. Anal cerclage has been described in the literature as a palliative procedure, with a 30% recurrence rate and specific morbidity due to prosthesis rejection or infection [5]. However, what makes the technique so attractive is the fact that it is a simple, short and less invasive procedure. Successful modifications of the procedure using various prosthetic materials to reach better short- and long-term results have been described (Table 2) [15–20]. Poole et al. [16] used vascular Dacron prostheses in 15 patients with a mean age of 65 years and a 50-month follow-up; morbidity was 33% (prosthesis infection and removal) and recurrence rate was 26%, with 2 patients undergoing re-cerclage. Earnshaw and Hopkinson [17] used silicone prostheses in 21 patients with a mean age of 66.5 years; the infection rate was 30%, the rate of prosthesis removal was 10% and the recurrence rate was 24% within an 86-month follow-up. Seventy-six percent of the patients acknowledged an improvement in their degree of continence [17]. Khanduja et al. [18], using the same material in 16 patients, reported a morbidity of 31% (including fracture of the material in 3 cases) and a recurrence rate of 19% within a 2-year follow-up. Jackman et al. [19] also used silicone prostheses in 52 patients, 90% of them over 60

109

years of age. The authors reported recurrence in 15 patients (28.9%), of which 11 underwent a new cerclage, reaching satisfactory results in 89% of the cases [19]. Saino et al. [20] reported 14 patients with a mean age of 74 years, who underwent an anal encirclement procedure using polypropylene mesh. The morbidity was 59% (mainly due to urinary retention and urinary infection) and the recurrence rate was 14%. Sixty-five percent of the patients stated having had a normal postoperative continence [20]. The present work evaluated 22 patients treated with anal cerclage with the Lomas-Cooperman technique (18% of them with a recurrent RP) using a hand-sewn piece of polypropylene mesh. Patients were all elderly with a mean age of 84 years, a much higher figure than those reported by the series in the literature [15–20]. The procedure we used consists of a quite easy to perform and reproducible minor surgery. Though overall morbidity at the immediate postoperative period reached 32%, most of the cases were due to urinary tract infection. However, there was one case of perineal gangrene requiring colostomy, resulting in a prolonged hospital stay. Although there were two recurrences (9%), one of them was successfully re-operated to introduce a new cerclage and, thus, the global recurrence, analysed on an intention-to-treat basis, was 4.5%. Overall, continence improved in 55% of the cases. Constipation is not uncommon after anal encirclement and it is important that a regular laxative is prescribed to prevent this. It is difficult to ascribe the faecal impaction, observed in 23% of the patients in this series, exclusively to the technique. In fact, the latter is a common complication appearing spontaneously in elderly patients, particularly those living in nursing homes. The scant attention brought forth by this technique among peers has been verified by the small number of publications regarding the procedure in the literature [21]. Nevertheless, as opposed to the traditional opinion, we do

Table 2 Variation in the anal cerclage technique for rectal prolapse, and outcomes, 1980-present Reference

Year

Patients, n

Prosthesis

Morbidity

Follow-up, months

Recurrence rate, %

Jackman et al. [19]

1980

52

Silicone

NS

24

29

Hunt et al. [15]

1985

41

Silicone

30% infection

12

30

Poole et al. [16]

1985

15

Dacron

33% infection and removal

50

26

Earnshaw and Hopkinson [17]

1987

21

Silicone

30% infection 10% removal

86

24

Khanduja et al. [18]

1988

16

Silicone

31%

24

19

Sainio et al. [20]

1991

14

Polypropylene mesh

59% infection and urinary retention

42

14

Present series

2006

22

Polypropylene mesh

18% exteriorisation

32

4.5a

a

Intention-to-treat basis; NS, not stated

110

not believe anal encirclement to be a palliative procedure for the management of RP in frail and elderly patients. Alternative perineal repairs (plication, resection) are major surgical procedures more suitable for a lower-risk patient, and thus, eventually suitable for abdominal surgery. The Lomas-Cooperman procedure is, according to our experience, an effective therapy for the management of complete rectal prolapse in extremely high-risk patients who are unfit for major abdominal surgery.

J.E. Mansilla et al.: Lomas-Cooperman technique for rectal prolapse

15.

16.

17.

18.

References 19. 1. Goldberg SM, Gordon PH, Nivatvongs S (1980) Essentials of anorectal surgery. JB Lippincott, Philadelphia, pp 248–268 2. Watkins BP, Landercasper J, Belzer GE et al (2003) Longterm follow-up of the modified Delorme procedure for rectal prolapse. Arch Surg 138:498–502 3. Wu JS, Fazio VW (2003) Surgical intervention for adult patients with rectal prolapse. Curr Gastroenterol Rep 5:425–430 4. Madoff RD (1998) Rectal prolapse and intussusception. In: Beck DE, Wexner SD (eds) Fundamentals of anorectal surgery. WB Saunders, London, pp 99–114 5. Madiba TE, Baig MK, Wexner SD (2005) Surgical management of rectal prolapse. Arch Surg 140:63–73 6. Lomas MI, Cooperman H (1972) Correction of rectal procidentia by polypropylene mesh (Marlex). Dis Colon Rectum 15:416–419 7. American Society of Anesthesiologists (1963) New classification of physical status. Anesthesiology 24:111 8. Karnofsky DA, Abelmann WH, Graver LF et al (1948) The use of nitrogen mustards in the palliative treatment of carcinoma. Cancer 1:634–656 9. Pescatori M, Anastasio G, Bottini C, Mentasti A (1992) New grading and scoring for anal incontinence. Evaluation of 335 patients. Dis Colon Rectum 35:482–487 10. Chun SW, Pikarsky AJ, You SY et al (2004) Perineal rectosigmoidectomy for rectal prolapse: role of levatorplasty. Tech Coloproctol 8:3–8 11. Zbar AP, Takashima S, Hasegawa T, Kitabayashi K (2002) Perineal rectosigmoidectomy (Altemeier’s procedure): a review of physiology, technique and outcome. Tech Coloproctol 6:109–116 12. Tsunoda A, Yasuda N, Yokoyama N et al (2003) Delorme’s procedure for rectal prolapse: clinical and physiological analysis. Dis Colon Rectum 46:1260–1265 13. Villanueva Saenz E, Martinez P, Alvarez-Tostado J (2003) Helicoidal suture: alternative treatment for complete rectal prolapse in high-risk patients. Int J Colorectal Dis 18:45–49 14. Bachoo P, Brazzelli M, Grant A (2000) Surgery for complete

20.

21.

rectal prolapse in adults. Cochrane Database Syst Rev (2):CD001758 Hunt TM, Fraser IA, Maybury NK (1985) Treatment of rectal prolapse by sphincteric support using silastic rods. Br J Surg 30:86–88 Poole GV, Pennell TC, Myers RT, Hightower F (1985) Modified Thiersch operation for rectal prolapse. Technique and results. Am Surg 51:226–229 Earnshaw JJ, Hopkinson BR (1987) Late results of silicone rubber perianal suture for rectal prolapse. Dis Colon Rectum 30:86–88 Khanduja KS, Hardy TG Jr, Aguilar PS et al (1988) A new silicone prosthesis in the modified Thiersch operation. Dis Colon Rectum 31:380–383 Jackman FR, Francis JN, Hopkinson BR (1980) Silicone rubber band treatment of rectal prolapse. Ann R Coll Surg Engl 62:386–387 Sainio PA, Halme LE, Husa AI (1991) Anal encirclement with polypropylene mesh for rectal prolapse and incontinence. Dis Colon Rectum 34:905–908 Karulf RE, Madoff RD, Goldberg SM (2001) Rectal prolapse. Curr Probl Surg 38:771–832

Invited comment This is an excellent paper. The authors present a substantial number of patients with an adequate indication for treatment. Mean age of the group is 84 years and most patients presented with severe associated diseases. Encirclement of the anal canal, first described by Thierch in 1891 and often used in the past, was progressively abandoned because of the high incidence of recurrence and the frequency of complications, mainly represented by wire breakage and infection. Introduction of new materials reduced this inconvenience but, even so, its use has been limited to extremely frail patients not able to undergo more radical and definitive procedures. This paper represents a revival of the encirclement technique using the mesh procedure which, in my point of view, still can be used for selected patients. However, it is worthwhile to consider that despite is a simple technique, severe complication may occur as was presented in the authors’ series. A. Habr-Gama Department of Surgery University of Rio de Janeiro, Brazil