Rectal Reservoir Reduction Procedures for Internal Rectal Prolapse IRWIN R. BERMAN, M.D., MARJORIE S. HARRIS, R.N., INEZ T. LEGGETT
Berman IR, Harris MS, Leggett IT. Rectal reservoir reduction procedures for internal rectalprolapse. Dis Colon Rectum 1987;30:765-771. Forty-four patients presenting with painful outlet constipation had internal rectal intussusceptiondocumented by cinedefecography.Rectal reservoir reduction by multiple elastic ligation or staple excisionof redundant mucosa effectively improved bowel function and outlet symptoms in the majority of patients. Rectal reduction procedures were performed under intravenous sedation with antibiotic coverage, no postoperativesepsis, and a single case of significant postoperative
bleeding. Associatedabnormalities on defecographywere unaffected. [Keywords: Rectalprolapse; Outlet constipation; Cinedefecography]
OBSTINATE CONSTIPATION associated with tenesmus, incomplete evacuation, and s~nsations of rectal outlet blockage are frequent symptoms in patients consulting a colon and rectal surgeon.l-3 Whether referred by a physician or by him or herself (more often herself), the patient usually has had thorough colonic evaluation with no definitive diagnosis. Many patients have been dismissed with no specific explanation of their symptoms or with one of the "amoeboid," last-resort diagnoses often ending with the word "syndrome.'4 There is considerable clinical overlap in the entities that may be associated with obstinate outlet constipation ( i n t e r n a l i n t u s s u s c e p t i o n , rectocele, p u b o r e c t a l i s syndrome, descending perineum). Since these entities usually escape conventional gastrointestinal diagnostic
From Glynn Brunswick Memorial Hospital, Brunswick, Georgia and Mercer University Medical School, Macon, Georgia
studies, cinedefecography5,6 was employed in approximately 500 patients presenting with this symptom complex and with physical findings supporting a diagnosis of outlet constipation. This paper documents the study and the treatment by reduction in rectal reservoir of 44 patients (39 females; five males) whose defecography documented internal rectal prolapse4,7, 8 and whose symptoms were refractory to vigorous nonoperative measures. T h e general preoperative profile of these patients is described in Table 1 in terms of symptoms, signs, and other factors. Materials and M e t h o d s
Read at the meeting of the American Societyof Colon and Rectal Surgeons, April 5 to 10, 1987,Washington, D.C. Address reprint requests to Dr. Berman: Colon and Rectal Clinic, 2301 Parkwood Drive, Brunswick, Georgia 31520.
Sigmoidoscopy during the Valsalva maneuver and cinedefecography in the sitting position were performed as previously described 4 in all patients whose history suggested outlet constipation a n d / o r internal rectal prolapse. Patients whose history, physical findings, and defecography supported a diagnosis of internal rectal prolapse were advised specifically regarding increased dietary water and bulk (bran and psyllium), sometimes supplemented with an oral osmotic agent. Intrarectal hydrocortisone foam, 1 percent, was used for its theoretical benefit in diminishing irritation of mucosal surfaces abrading one another in internal intussusception. Those patients whose symptoms remained severe in spite of these measures and who had the most significant internal
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TABLE 1. Patient Profile Symptoms
Signs
Megarectum Constipation Infrequent and Strain--intussusception difficult Mucosal prolapse Sensation of Proctitis or "blockage" friability Rectal pain or Solitary rectal pressure Radiation to ulcer buttocks and thighs "Ball in rectum" Tenesmus Multiple small stools Incomplete evacuation Passage of bloody 1T~UCUS
Need for manual aids
Other Mostly women Negative GI evaluation Multiple physicians Previous gynecological or rectal procedure Irritable bowel or neurotic label
October1987
prolapse were offered Delorme's transrectal excision of the redundant mucosal tube. Inspired by the previous success of Uhlig and Sullivan9 and by personal experience4 with reduction of rectal reservoir by the Delorme procedure, two lesser reductive procedures were applied subsequently to other medically refractory patients (Fig. 1). Patients selected for these procedures were those whose persistent symptoms and defecography were less severe than those deemed suitable for the Delorme procedure. Thirty-six patients (33 females; three males, aged 29 to 90 years) in this lesser category were treated between March 1985 and March 1986 by a technique of multiple elastic band ligation of redundant rectal mucosa, extending in three rows from just above the dentate line to as high as possible into the rectal ampulla, as previously described. 4 Most of these patients were ligated in a single-stage
FIG. 1. Schematic description of operative options for rectal reservoir reduction in patients with internal intussusception and obstinate outlet constipation.
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T.~BLE2. Rectal Reservoir Reduction-Multiple Ligation Technique Symptoms
rI
Constipation Time with B.M. Laxative use Blockage symptoms Back/rectal pain Need for pressure females only)
Relieved 30 (83.3%) 36 (100) 26 (72.2) 22 (61.1) 29 (80.5) 22 (66.7)
hnproved
Unchanged
6 (16.7%) 10 (27.8) 13 (36.1) 6 (16.7) 10 (30.3)
l (2.8) I (2.8) 1 (3.0)
f
FIG.2. Graphic illustration of application of linear stapler-cutter in vertical rows for reduction of internal rectal prolapse.
procedure, loading four to five bands at a time on the instrument. T h e lowest elastic bands were applied with the smallest Hill-Furgeson retractor in the anal canal. More proximal bands were usually applied with no retractor in place to avoid countertraction on the remaining mucosa during application. For proximal ligatures, downward traction was applied to the lower banded segment and the bander, with an Allis c l a m p contained, was then guided digitally to each next higher segment. In this manner as m a n y as 12 to 15 segments were banded (three to five per row) until all redundancy was reduced. T o date, a total of 65 patients have been treated using the multiple ligation technique. Another g r o u p of eight patients with similar clinical profiles (six females; two males, aged 32 to 76 years), but with more redundancy than could effectively be encompassed in the elastic ligatures, were treated between May and August 1986 by application of two linear rows of staples in a similar vertical configuration, from just above the dentate line well up into the rectal a m p u l l a (Fig. 2). Midline anterior application was generally avoided. Staple application was accomplished using the Ethicon Linear Stapler Cutter. | Usually two applications of the stapler were required for each linear row, the second (cephalad) application facilitated by downward traction on the apex of the lower (caudad) initial row of staples. On several occasions a third row of staples could be applied or an elastic ligature applied to a segmental
residual segment of remaining redundant mucosa. T o date, a total of 14 such procedures have been performed in our practice. Both the multiple ligation and staple excision procedures, as well as the Delorme procedure, are graphically depicted in Fig. 1. All patients in both groups had intact rectal sphincters and none were incontinent preoperatively. Preoperative defecography was always confirmatory for internal intussusception. All patients were prepared for the rectal reductive procedures with preoperative enemas and almost all procedures were performed in a single stage using heavy intravenous sedation. Intravenous antibiotics were always used preoperatively and postoperatively in patients treated by a single-stage procedure for either technique. Patients were evaluated at regular intervals ( m i n i m u m follow-up, one year with multiple ligation; m i n i m u m , six months with staple excision). Patients were interviewed by an independent examiner with regard to clinical parameters documented in Tables 2 and 3 and Figs. 3 and 4. Results
Cinedefecography in these patients confirmed internal rectal intussusception in all 44 cases, with associated rectocele in approximately one third of patients, perineal descent over 4.0 cm in one third of patients, and occasional enterocele or inability to evacuate instilled barium. There were no septic complications in any patient of either group, and no evidence of postoperative peritoneal irritation or loss of continence. Scant rectal bleeding was c o m m o n p l a c e for up to several weeks but was significant
TABLE3. Rectal Reservoir Reduction-Staple E: cision Technique Symptom Constipation Time with B.M. Laxative use Blockage symptoms Back/rectal pain Need for pressure (females only)
Relieved 7 (87.5%) 8 (100) 5 (62.5) 5 (62.5) 8 (100) 5 (62.5)
Improved 3 (37.5) 3 (37.5) 1 (37.5)
Unchanged 1 (12.5)
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FIG.3A,B. Graphic representation of clinical results ol muhiple l~gation techrtique in 36 patients, symptoms grouped by categorywith regard to bowel [unction or outlet discomfort (minimum follow-up one year).
in only one patient (who did not require transfusion). Postoperative pain was slightly more than for single band ligation but almost always less than for surgical hemorrhoidectomy, rarely lasting more than several days. Pain with initial bowel evacuation occurred fairly frequently but was rarely severe. Transient urinary retention was commonplace, often requiring overnight catheter placement. Return to work or an active social life was usually possible within one to two weeks. Patient results were
evaluated in terms of parameters cited in Tables 2 and 3 and Figs. 3 and 4. Results of both ligation and staple excision techniques were comparable, with approximately 85 percent noting relief and approximately 10 to 15 percent noting improvement of the presenting symptoms of constipation, time required for bowel evacuation, and dependence u p o n laxatives. Relief of symptoms of outlet blockage was somewhat less predictable, with only about two thirds of patients totally relieved but most
FIG.4A,B. Graphic representation of clinical results of staple-excisiontechnique in eight patients, symptoms grouped by categorywith regard to bowel function or outlet discomfort (minimum follow-up six months).
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FIG. 5. Preoperative and postoperative defecography in a male patient for whom multiple ligation was applied [or internal rectal mucosal prolapse.
patients either relieved or improved. These results are expressed in terms of each isolated s y m p t o m in Tables 2 and 3. Tissue removed in the staple-excised specimens showed both mucosa and focal areas of submucosa. A preoperative and postoperative defecography study for each of the two categories of procedure is shown in Figs. 5 and 6, each illustrating the desired effect of rectal reservoir reduction.
Discussion These results suggest that rectal reservoir reduction by a n u m b e r of methods (Fig. 1) can provide relief of symptomatic, medically refractory, internal rectal intussusception, and outlet constipation.4, 9 These beneficial effects are predictable, lasting (at least to the limits of follow-up) and appear to be independent of the correction of coexistent anatomic abnormalities, including rectocele, enterocele, perineal descent or rectosacral separation (mesosigmoid). 4 T h e two most p o p u l a r current therapeutic extremes for this entity amongst surgeons include abdominal rectopexy, 7 with or without resection, and, more recently,
FIG. 6. Preoperative and postoperative defecographyin a femalepatient for whom staple excision was applied for internal intussusception and rectal mucosal prolapse.
application of biofeedback t~ or division of the puborectalis 11 to patients whose failure to evacuate instilled barium suggests an overactive puborectalis muscle, t2 Whether the latter approaches have merit for selected patients is not the subject of this paper, although some have supposed that a nonrelaxing puborectalis may be etiologic in the pathogenesis of internal rectal intussusception, t3 T h e confusing aspect of the hypothesis of the nonrelaxing puborectalis as a specific pathophysiologic entity t~ t~ is the failure of puborectalis overactivity, as seen on defecography, to correlate predictably with symptoms and the failure of surgical division of the puborectalis to be accompanied by predictable disappearance of symptoms or the radiographic "defect" u p o n which the diagnosis had depended, tl Certainly an intact sphincter complex was c o m m o n to all of these patients. In some, an exaggerated puborectalis impression was noted and evacuation of barium was inadequate. It is not known to what extent these findings may relate to the solution of the clinical problem. T h e question of abdominal vs. perineal procedures in the correction of internal rectal intussusception is also of interest. Application of abdominal procedures to the
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solution of obstructing distal internal intussusception appears flawed, both pathophysiologically and anatomically.4, ~4,,5 Indeed, the application of a distal (endorectal or transrectal) procedure for constipating distal intussusception becomes all the more attractive when one considers the frequency of persistent or worsening constipation with the transabdominal procedures. 14,15 More likely than not, internal intussusception is an entity unto itself rather than a precursor of frank external prolapse, to which the abdominal approach is eminently suited. 16 Unlike some of the a b d o m i n a l procedures, rectal reservoir reduction by any of the three methods described does not address other anatomic abnormalities, but usually affords relief of symptoms without deliberate correction of associated abnormalities (including, in some cases, nonrelaxing or overactive puborectalis). However, some reduction in rectocele size usually accompanied reservoir reduction. These facts suggest that reservoir reduction alone may be sufficient for symptomatic relief, at least in the framework of this period of follow-up. Every recent panel on therapy of constipating internal intussusception has included a c o m m e n t that one must avoid the neurotic or hysterical patient, for w h o m a surgical misadventure m a y be disastrous. There is no question that traditional abdominal rectopexy, however gilded by technical embellishments, will be associated with persistent or worsening constipation in some patients (often translating to the surgeon as "worsening hysteria"). By contrast, bowel function has not worsened in any patients in this series and two presumably hysterical women, ages 16 and 37, whose families had dispensed with them as psychiatric cases, had their psychiatric problems essentially resolved coincident with the restoration of predictable bowel evacuation. Obviously, as with any therapy, it is wise to approach certain patients with caution, especially those w h o expect an instantaneous result, nonc o m p l i a n t personalities, a n d those w h o have been "collectors" of doctors, operations, or medications. Affording the patient a three-to-six-month nonoperative hiatus will usually allow one to sort out the individual w h o is probably less likely to have a dramatically successful result, regardless of the procedure. T h e beneficial effect of rectal reservoir reduction in these patients is probably the result of the combined mechanical effect of conversion of the patulous megarecturn to a more tubular configuration and to elimination of the obstructing internal intussusception. 4 T h e safety of single-stage ligation techniques for hemorrhoids has been documented 17and their use has been extended to this patient population. Application of multiple ligatures to external prolapse was reported as early as 1923 by Gant, 's a procedure that's theoretic benefit included the bonding of mucosa to submucosa by the resulting eschar. The predictable inclusion of submucosa in some portion of the staple
excision technique, as opposed to the ligation technique, would theoretically afford more lasting benefit in this regard, as with Block's obliterative suture as applied to rectocele. '9 T h e staple excision technique may thus be regarded as a high-tech blending of earlier, less sophisticated techniques, using c l a m p and cautery or linear application of sclerosants. Nonetheless, the authors believe its use is probably best limited to the older or more fragile patient for w h o m ligation may be insufficient but a more extensive operation too debilitating. Application of multiple elastic ligatures or stapling may be supplemented in postoperative months by additional bands as needed if symptoms become recurrent. Although pelvic sepsis ~~ has been described with even single-band elastic ligation of rectal mucosa, none of these patients developed such problems, even with k n o w n inclusion of submucosa in staple-excision lines. More than likely, true pelvic sepsis in the context of elastic ligation depends on preexisting d o r m a n t infection in perirectal lymphatics that m i g h t act synergistically with ischemic or necrotic banded tissue. Optimally, elastic bands should be applied only after enema or in the absence of significant stool in the rectum, even in the office setting. A short course of antibiotics with application of bands may have further theoretical benefit in some patients. T h e association of outlet constipation and internal intussusception with other anatomic abnormalities on defecography suggests that solitary rectal ulcer, descending perineum, levator syndrome, and possibly the spastic pelvic floor syndrome, may be related entities or elements in a c o n t i n u u m of rectal disorders associated with laxity (or hyperactivity) of all or part of the anorectum and its supporting structures.
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MM, Swash M. Coloproctology and the pelvic floor. London: Butterworths, 1985:151-86. Uhlig BE, Sullivan ES. The modified Delorme operation: its place in surgical treatment for massive rectal prolapse. Dis Colon Rectum 1979;22:513-21. Bleijenberg G, Kuijpers HC. Treatment of the spastic pelvic floor syndrome with biofeedback. Dis Colon Rectum 1987;30:108-11. Hawley PR. Symposium on rectal prolapse. 4th Annual Course in Colon and Rectal Surgery. Sansum Clinic, Santa Barbara, CA, February 27, 1987. Kuijpers HC, Bleijenberg G, de Morree H. The spastic pelvic floor syndrome: large bowel obstruction caused by pelvic floor dysfunction. Int J Colorect Dis 1986;1:44-8. White CM, Findlay JM, Price JJ. The occult recta/prolapse synch'ome. Br J Surg 1980;67:528-30. Holmstr6m B, Brod~n G, Dolk A. Results of the Ripstein opera-
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tion in the treatment of rectal prolapse and internal rectal procidentia. Dis Colon Rectum 1986;29:845-8. Gordon PH, Hoexter B. Complications of the Ripstein procedure. Dis Colon Rectum 1978;21:277-80. Theuerkauf FJ Jr, Beahrs OH, Hill JR. Rectal prolapse: causation and surgical treatment. Ann Surg 1970;171:819-35. Poon GP, Chu KW, Lau WY, et al. Conventional vs triple rubber band ligation for hemorrhoids: a prospective, randomized trial. Dis Colon Rectum 1986;29:836-8. Gant SG. Procidentia ani, recti and sigmoid. In: Diseases of rectum, anus and colon. Philadelphia: WB Saunders, 1923:39. Block I. Transrectal repair of rectocele using obliterative suture. Dis Colon Rectum 1986;29:707-11, Clay LD, White JJ Jr, Davidson JT, Chandler JJ. Early recognition and successful management of pelvic cellulitis following hemorrhoidal banding. Dis Colon Rectum 1986;29:579-81.