Management of Recurrent Rectal Prolapse Scott A. Fengler, M.D.,* Russell K. Pearl, M.D.,~M. Leela Prasad, M.D.,t Charles P. Orsay, M.D.,-I-Jose R. Cintron, M.D.,~ Ernestine Hambrick, M.D.,]] Herand Abcarian, M.D.q[ From the *F. Edward Herbert School of Medicine, Uniformed Services University of the Health Sciences, Brooke Army Medical Center, Ft. Sam Houston, Texas, the tDivision of Colon and Rectal Surgery, Cook County Hospital, Chicago, Illinois, the ,University of Illinois-Chicago, Lutheran General Hospital, Park Ridge, Illinois, the ~University of Illinois-Chicago, West Side VA Hospital, Chicago, Illinois, the ]]University of IllinoisChicago, Michael Reese Hospital and Medical Center, Chicago, Illinois, the q[Department of Surgery, University of Illinois-Chicago, Chicago, Illinois PURPOSE: Many operations have been described for the management of rectal prolapse. Despite an overall recurrence rate of greater than 15 percent, few reviews address how to deal with this problem. This report summarizes our experience with recurrent rectal prolapse and includes suggestions for reoperative management of failed repairs from both abdominal and perineal approaches. PATIENTS AND METHODS: Fourteen patients (3 male) ranging in age from 22 to 92 (mean, 68) years underwent operative correction of recurrent rectal prolapse. Average time from initial operation to recurrence was 14 (range, 6-60) months. Initial operations (before recurrence) were as follows: perineal proctectomy and levatorplasty (10), anal encirclement (2), Delorme's procedure (1), and anterior resection (1). Operative procedures performed for recurrence were as follows: perineal proctectomy and levatorplasty (7), sacral rectopexy (abdominal approach; 3), anterior resection with rectopexy (2), Delorme's procedure (1), and anal encirclement (1). Average length of follow-up was 50 (range, 9-115) months. RESULTS: No further episodes of complete rectal prolapse were observed during this period. Preoperatively, three patients were noted to be incontinent to the extent that necessitated the use of perineal pads. The reoperative procedures failed to restore fecal continence in any of these three individuals. One patient died in the postoperative period after anal encirclement from an unrelated cause. CONCLUSION: Surgical management of recurrent rectal prolapse can be expected to alleviate the prolapse, but not necessarily fecal incontinence. Perineal proctectomies can be safely repeated. Resectional procedures may result in an ischemic segment between two anastomoses, unless the surgeon can resect a previous anastomosis in the repeat procedure. Nonresectional procedures such as the Delorme's procedure should be strongly considered in the management of recurrent rectal prolapse if a resectional procedure was performed initially and failed. [Key words: Rectal prolapse; Recurrence; Procidentia; Surgery]

Hambrick E, Abcarian H. Management of recurrent rectal prolapse. Dis Colon Rectum 1997;40:832-834. A

m u l t i t u d e o f o p e r a t i o n s h a v e b e e n d e s c r i b e d for the m a n a g e m e n t o f rectal p r o l a p s e 1' 2 a n d include abdominal and perineal approaches with and w i t h o u t resection. Each o p e r a t i o n h a s its o w n indications a n d a d v a n t a g e s in a p a r t i c u l a r s u b s e t o f patients. Little i n f o r m a t i o n is a v a i l a b l e in the literature r e g a r d ing m a n a g e m e n t o f r e c u r r e n t rectal p r o l a p s e , d e s p i t e r e c o g n i t i o n o f a definite t e n d e n c y for r e c u r r e n c e in this disorder. 2 It is t h e p u r p o s e o f this r e v i e w to p r e s e n t o u r e x p e r i e n c e w i t h t h e surgical c o r r e c t i o n o f r e c u r r e n t rectal p r o l a p s e a n d m a k e s u g g e s t i o n s for patient management.

PATIENTS

AND

METHODS

W e r e v i e w e d the m e d i c a l r e c o r d s o f all p a t i e n t s o p e r a t e d o n for r e c u r r e n t rectal p r o l a p s e d u r i n g a t e n - y e a r p e r i o d . B e t w e e n N o v e m b e r 1984 a n d Sept e m b e r 1993, 14 p a t i e n t s (3 m a l e ) u n d e r w e n t o p e r a tive m a n a g e m e n t o f r e c u r r e n t rectal p r o l a p s e . Patients r a n g e d in a g e f r o m 22 to 92 ( m e a n , 68) years. T i m e f r o m initial p r o c e d u r e to o p e r a t i o n for r e c u r r e n c e r a n g e d f r o m 6 to 60 ( m e a n , 14) m o n t h s . Initial o p e r ations ( b e f o r e r e c u r r e n c e ) i n c l u d e d p e r i n e a l p r o c t e c t o m y a n d l e v a t o r p l a s t y (10), a n a l e n c i r c l e m e n t (2), D e l o r m e ' s p r o c e d u r e ( m u c o s a l s t r i p p i n g a n d rectal m u s c u l a r i s plication; 1), a n d a n t e r i o r r e s e c t i o n (1). O p e r a t i o n s p e r f o r m e d for r e c u r r e n c e s w e r e p e r i n e a l p r o c t e c t o m y a n d l e v a t o r p l a s t y (7), sacral r e c t o p e x y ( a b d o m i n a l a p p r o a c h ; 3), a n t e r i o r r e s e c t i o n w i t h rect o p e x y (2), D e l o r m e ' s p r o c e d u r e s (1), a n d a n a l encirc l e m e n t (1). In p a t i e n t s w h o u n d e r w e n t p e r i n e a l p r o c t e c t o m y as their initial p r o l a p s e o p e r a t i o n , t h e o p e r a t i o n s u s e d for r e c u r r e n c e s w e r e p e r i n e a l p r o c -

Fengler SA, Pearl RK, Prasad ML, Orsay CP, Cintron JR, The opinions or assertions contained here are the private views of the authors and are not to be construed as reflecting the views of the Departments of the Army or Defense. Poster presentation at the meeting of the American College of Surgeons, Chicago, Illinois, October 9 to 14, 1994. Address reprint requests to Dr. Fengler: ATTN:MCHE-SDG, Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston Texas 78234-6200. 832

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RECURRENT RECTALPROLAPSE

tectomy and levatorplasty (5), sacral rectopexy (abdominal approach; 3), anterior resection with rectopexy (1), and anal encirclement (1). In patients w h o initially underwent anal encirclement, the operations used for recurrences were perineal proctectomy (1) and anterior resection with rectopexy (1). The patient with recurrence after anterior resection underwent a Delorme's procedure, and the patient w h o initially underwent a Delorme's procedure underwent a perineal proctectomy for recurrence. Average length of follow-up was 50 (range, 9-115) months. RESULTS One patient died in the postoperative period after anal encirclement from an occult esophageal perforation secondary to dilation for benign esophageal stricture. One patient sloughed a segment of rectal mucosa after an anterior resection with rectopexy for recurrent rectal prolapse. This patient had previously undergone a perineal proctectomy with levatorplasty for the initial episode of prolapse. No further episodes of complete rectal prolapse were observed during the follow-up period. Three patients were incontinent to the extent that daily perineal pads were used. One patient underwent perineal proctectomy as an initial and repeat procedure. The second patient underwent a Delorme's procedure initially, followed by a perineal proctectomy for recurrence. The third patient underwent a perineal proctectomy initially, followed by an anterior levatorplasty and external anal sphincteroplasty for recurrence. M1 three of these patients were completely incontinent before and following both their initial procedure for rectal prolapse and the repeat procedure. DISCUSSION Although a multitude of operations have b e e n described for the management of complete rectal prolapse, a review of the literature revealed no references pertaining specifically to the management of recurrent rectal prolapse. Success has b e e n reported in repeating the same operation for recurrent prolapse. 3-6 Recurrence after prosthetic sacral rectopexy using a polytetrafluoroethylene sling has been effectively treated by replacing the sling and by resuspending the rectum to the sling. 7 Surgeon preferences and patient risk factors are key in the decision-making process w h e n choosing an operation for rectal prolapse. Despite the familiarity and high success rate of

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abdominal approaches in the repair of rectal prolapse, it is advisable to opt for a perineal approach in high-risk patients. Likewise, w h e n any of several options are acceptable choices in the repair of rectal prolapse, it is advised that surgeons choose the procedure with which they are most familiar. An additional important factor in choosing an operation for recurrent rectal prolapse is the previous procedure. This point is underscored by the slough of rectal mucosa reported in this series in the patient who underwent anterior resection with rectopexy for recurrent rectal prolapse after perineal proctectomy with levatorplasty had b e e n performed as the initial procedure. This is caused by ischemia of the rectal segment between the two anastomoses. Unless the previous anastomosis is resected in a procedure for recurrent rectal prolapse, resectional procedures should be avoided. Potentially ischemic segments of bowel between anastomoses are subject to mucosai slough, stricture, and anastomotic dehiscence. Because of the fact that recurrence after perineal proctectomy will invariably prolapse the previous anastomotic line, no ischemic segment will be present if another perineal proctectomy is performed. This review demonstrates that recurrent rectal prolapse can be managed surgically with a high likelihood of success in alleviating the prolapse. However, fecal incontinence is less likely to improve. CONCLUSIONS Reoperation is uniformly successful in alleviating recurrent rectal prolapse but not necessarily the associated fecal incontinence. Perineal proctectomies can be repeated safely. Repeat resectional procedures, such as anterior resection following perineal proctectomy or vice versa, are likely to result in complications attributable to ischemia of the intervening segment between anastomoses. Unless the surgeon is able to remove the previous anastomosis during reoperation, this approach should be avoided. For this reason, nonresectional procedures such as the Delorme's procedure should be strongly considered in the management of recurrent rectal prolapse initially treated by anterior resection.

REFERENCES 1. Kuijpers HC. Treatment of complete rectal prolapse: to narrow, to wrap, to suspend, to fix, to encircle, to plicate or to resect? World J Surg 1992;16:826-30. 2. Goldberg SM, Gordon PH, Nivatvongs S. Complications

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of surgery for complete rectal procidentia. In: Ferrari BT, Ray JB, Gathright JB, eds. Complications of colon and rectal surgery, prevention and management. Philadelphia: WB Saunders, 1985:251-66. 3. Thome MC, Polglase AL. Perineal proctectomy for rectal prolapse in elderly and debilitated patients. Aust N Z J Surg 1992;62:791~1. 4. Graf W, Ejerblad S, Krog M, et al. Delorme's operation for rectal prolapse in elderly or unfit patients. EurJ Surg 1992;158:555-7. 5. Williams JG, Rothenberger DA, Madoff RD, Goldberg

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SM. Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy. Dis Colon Rectum 1992;35: 830--4. Tjandra JJ, Fazio VW, ChurchJM, Milsom JW, OakleyJR, Lavery IC. Ripstein procedure is an effective treatment for rectal prolapse without constipation. Dis Colon Rectum 1993;36:501-7. 7. Lescher TJ, Corman ML, Coller JA, Veidenheimer MC. Management of late complications of Teflon| sling repair for rectal prolapse. Dis Colon Rectum 1979;22: 445-7. .