Results of Delorme's Procedure for Rectal Prolapse Advantages of a Modified Technique Jean Pierre Lechaux, M.D., David Lechaux, M.D., Michael Perez, M.D. From the Hopital des Diaconesses, Service de Chirurgie Digestive, Paris, France PURPOSE: A retrospective study was undertaken to assess
the results of Delorme's procedure for rectal prolapse and to determine the advantages of an innovative extended transrectal repair, which aims at performing a total pelvic floor repair. METHODS: A total of 85 patients, ranging in age from 21 to 97 years, were operated on. Sixty-five (82 percent) patients had varying degrees of fecal incontinence. Similar groups of patients were compared with regard to control of the prolapse and restoration of continence according to 1) age and medical condition and 2) operative technique: original vs. extended operation. RESULTS: Twelve patients (14 percent) developed postoperative complications. There was one perioperative death (1.2 percent). Eighty patients were followed for 6 to 136 (median, 33) months. Eleven (13.5 percent) developed recurrent full-thickness prolapse. The recurrence rate was sigtlificantly different 1) between 44 elderly and poor operative risk patients not suitable for abdominal surgery (22.5 percent) and 41 younger patients without concurrent medical conditions, electively submitted to perineal repair (5 percent) (P < 0.05), and 2) between the original procedure (21 percent of 44 patients) and the modified technique (5 percent of 41 patients) (P < 0.05). Forty five patients (69 percent) improved or regained hill continence. No patient worsened. No residual dysfunction was induced. Restoration of continence was not influenced by selection of patients or surgical technique. CONCLUSIONS: Despite increased morbidity (22 percent; P < 0.05), advantages of the modified technique were 1) over the original procedure, a reduced recurrence rate, 2) over perineal proctectomy, the absence of coloanal anastomosis and better functional outcome, and 3) over abdominal rectopexy, a less aggressive approach without disturbing effects on bowel habits. [Key words: Rectal prolapse; Delorme's procedure; Fecal incontinence; Endorectal repair; Levatorplasty] Lechaux JP, Lechaux D, Perez M. Results of Delorme's procedure for rectal prolapse: advantages of a modified technique. Dis Colon Rectum 1995;38:301-307. any procedures have been reported in the management of rectal prolapse. Their concepts are based on the correction of anatomic disorders associated with procidentia. Most are successful in terms of control of prolapse. However, disorders of rectal function, persistence of incontinence, or residual disturbances of defecation are the main causes of dissatisfaction for patients. Because of the lack of under-
M
standing of the pathophysiology, the most appropriate strategy remains unknown. The purpose of this report is to assess the effects on prolapse and rectal function of Delorme's procedure in a series of 85 patients. An innovative extended operation devised to improve the results will be described and evaluated.
MATERIALS A N D M E T H O D S From 1976 to 1992, 85 patients (77 females and 8 males), ranging in age from 21 to 97 (mean, 68) years, underwent 88 Delorme's procedures for the correction of full-thickness rectal prolapse (Fig. 1). Twentyseven patients (31 percent) were aged over 80 years. Five patients had undergone one previous surgery: one insertion of Thiersch wire, one abdominal rectopexy, one abdominal omentopexy, and two periheal procedures. One patient had undergone surgery twice: anal encirclement and abdominal rectopexy. According to age and medical condition, two groups of patients have been selected. Forty-four elderly and poor operative risk patients (median age, 82 years) were deemed unfit for abdominal repair (Group A). In 41 patients without any concurrent medical condition (median age, 55 years), it was the procedure of choice (Group B). For 79 patients, documented data were available on preoperative and postoperative anal control (Table 1). Sixty-five patients (82 percent) had varying degrees of fecal incontinence. Follow-up was conducted by telephone call or examination.
Technique The operation was performed in the lithotomy position after mechanical preparation of the rectum (Normacol| Norgan, Paris, France), with perioperatire intravenous antibiotics, under general (33 cases) or spinal anesthesia (46 cases) or light sedation with local infiltration of lidocaine (6 cases). The operative technique of the original Delorme's procedure has been described previously. 1'2 Fourty-four patients
Address reprint requests to Dr. Lechaux: Hopital des Diaconesses, 18 rue du Sergent Bauchat, 75012 Paris, France. 301
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25
'
2O ] 9
Ii
Females Males
E
L B B + 20 s
30 s
40 s
50 S
60
m ~ 70 S
80 S
90 S
Age of patients
Figure 1. Histogram of the age and sex of patients in
decades.
Table 1. Recurrence Following Delorme's Procedure (n = 80): Comparison Between Patient Groups No. of Patients
No. of Recurrences (%)
Group A 40 9 (22.5) Group B 40 2 (5)* Group I 42 9 (21) Group II 38 2 (5.25)* Group A = elderly and poor operative risk patients. Group B = younger and good risk patients. Group I = original Delorme's procedure. Group II = extended Delorme's procedure. * Significant P < 0.05.
have undergone surgery by this technique (Group I). Since 1990, an extended procedure has been devised and performed in 41 patients (Group II). Correction of all other abnormalities has been associated with the mucosectomy. Operative Technique. After completion of stripping of the mucosa to the apex of the prolapse, the prolapsed pouch of Douglas was exposed through a transverse incision of the anterior rectal musculature, dissected from the mesenteric vessels, excised, and sutured by two pursestring, absorbable sutures as high as possible (Figs. 2 and 3). The abnormally mobile and straight rectum was corrected by a spontaneous rectopexy to the sacral fascia. The presacral space was entered through the intersphincteric plane displayed by blunt dissection between the initial mucosal incision and the circular rectal musculature (Fig. 4). Using a wide upward dissection, an absorbable mesh (Vicryl| Ethicon, Sommerville, NJ, or Hemostagene| Sarbach, Suresnes, France) was inserted to enhance adhesion to the sacral fascia (Fig. 5). Like others, 3 the extent of rectal mobilization to the level of the third sacral body was assessed by insertion of
Figure 2, After completion of the mucosal dissection to the apex of the prolapse, a transverse opening of the anterior rectal wall has been performed. The prolapsed pouch of Douglas is exposed and grasped with Babcock's forceps.
clips at tile upper end of the dissection and postoperative x-rays. The diastasis of levator ani was corrected by preanal and postanal repair. Postanal repair was performed by approximating the puborectalis muscles through the posterior intersphincteric approach (Fig. 5). Repair of the perineal body was accomplished by preanal levatorplasty effected through the anterior muscular exposure with two or three absorbable sutures. Rectocele that is a constant feature was repaired according to Uhlig and Sullivan4 by vertical suture of the transverse muscular incision and anterior plication in one or two layers of the circular muscle in the vertical axis (Fig. 6). The purpose was to create a "funnel-shaped rectum having good muscular support ''4 and to strengthen the patulous atonic anus. The denuded rectal wall was then held in the supralevator position by longitudinal plication and narrowing of the pelvic outlet by levatorplasty. In some instances,
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Figure 3. The prolapsed cul-de-sac has been opened and dissected upward. Finally, it will be excised and sutured as high as possible.
fibrin glue was used as a sealant for coapting of tissues. Circumferential anastomosis of mucosal edges after excision of the mucosal sleeve was facilitated by the Lone Star@ (Lone Star Medical Products, Houston, TX) retractor. This technique is more time consuming (median duration, 90 min) and technically more demanding than the original procedure. Blood loss was minimal. Drainage and urinary catheters were not used. A regular diet was given. Bulk stool conditioners were frequently needed. Digital examination was done on the second postoperative day and repeated every day until discharge. The average in-hospital stay was seven days. Sphincter training was undertaken when technically feasible two months later by electrotherapy and sphincter contraction exercises.
Statistic Analysis Groups of patients and methods of treatment were compared using Student's paired test. Pvalues < 0.05 were considered significant. RESULTS One 93-year-old patient undergoing the extended operation died from cardiac failure in the postoperative period (in-hospital mortality rate, 1.2 percent). The operative mortality of the modified technique was thus 2.4 percent. Complications developed in 12 patients (14 percent). These included bleeding from the suture line in four patients w h o were treated
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// Figure 4. The intersphincteric plane has been opened by blunt dissection between the initial mucosal incision and circular rectal musculature (internal sphincter) in the posterior midline.
conservatively without blood transfusion and stenosis of the suture in 11 patients (13 percent) who required instrumental dilation or surgical incision in four instances. Seven percent of the patients undergoing the original technique experienced a complication as opposed to 22 percent of those undergoing the extended procedure (P < 0.05). Aside from postoperative death, no systemic complication, related to the medical condition of the patient, occurred. Two patients were lost to follow-up, and two patients died of medical conditions two months following surgery. The remaining 80 patients were followed for 6 to 136 (median, 33) months. Fifteen patients died after a mean follow-up of 26 months. Sixty-six patients (82.5 percent) were followed for more than one year, 45 patients (56 percent) for more than two years, and 27 patients (33.5 percent) for more than three years with a maximum of 11 years. Eleven patients (13.75 percent) developed recurrent full-thickness prolapse 3 to 39 (median, 17) months after surgery. Five intermit-
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Figure 5. Dissection has been continued upward in the presacral space to the third sacral body with insertion of absorbable mesh. Postanal levatorplasty is performed by approximating the puborectalis muscles.
Dis Colon Rectum, March 1995
and one failure. A Wells rectopexy was effected in two patients, with one postoperative death by pulmonary embolus. According to selection of patients (Table 1), the recurrence rate was 22.5 percent (9 cases) in Group A (poor operative risk) and 5 percent (2 cases) in Group B (first choice operation). This difference is significant (P < 0.05). These two groups were similar in terms of number of patients, duration of symptoms, and length of follow-up. According to the selection of procedure, nine patients (21 percent) treated by the original Delorme's procedure (Group I) had a failure, whereas two recurrences (5 percent) were observed after the extended procedure (Group II). This difference is significant (P < 0.05). Age, number of patients, and duration of symptoms were similar in Groups I and II, but the average follow-up was longer in Group I (47 months) than in Group II (17.5 months). With regard to continence (Table 2), 79 patients were available for postoperative evaluation. Among 65 incontinent patients, restoration of continence occurred in 29 (44.5 percent). Sixteen patients became continent to solid stools only and 20 remained unchanged, Thus, 45 patients (69 percent) improved or regained full continence. No patient was made worse. When comparing functional results according to selection of patients and selection of procedure, there were no significant differences. With regard to intestinal habits, immediate postoperative abnormalities of defecation with frequent stools and unconscious leakage related to decreased rectal compliance and hypersensitivity were frequently observed and gradually resolved. No residual dysfunction was induced or exacerbated, nine patients who complained of difficulties in the expulsion Table 2. Effect of Surgery on Continence in Seventy-Nine Patients Studied Postoperative Status No.
Figure 6. After upward longitudinal plication, the rectal wall is held in the supralevator position by levatorplasty. Downward, in the anterior midline, transverse plication is performed to repair the rectocele and internal anal sphincter defect.
tent mucosal prolapses were excluded. Three of 11 patients underwent repeat perineal repair by the same procedure with good long-term results in two cases
Preoperative Status No. (%)
(%)
Grade I
Grade II
Grade III
Grade I 14 (18) 14 Grade II 30 (38) 16 14 Grade III 35 (44) 13 16 6 Total 7g 43 (55) 30 (38) 6 (7) Grade I = fully continent. Grade II = incontinent for liquid stools and gas. Grade III = fully incontinent.
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of stools were cured, no genital or sexual disorders were reported by the younger patients, and a 26-yearold patient delivered a full-term infant without recurrence.
DISCUSSION Abdominal procedures for treatment of procidentia are presumed to entail better anatomic and functional results than perineal repair. Abdominal rectopexy has b e c o m e the most commonly performed operation, with a recurrence rate of 0 to 10 percent. 5 Frequency of fecal incontinence associated with rectal prolapse varies from 11 to 81 percent, 5 depending in part on the definition of incontinence. After rectopexy, about two-thirds of incontinent patients improved. 6 Persistence of incontinence and residual disorders of defecation are the main causes of dissatisfaction. Constipation and difficulties in evacuating the rectal ampulla occur in up to 50 percent of patients. 7-9 Division of the lateral ligaments 1~ and posterior dissection that lead to partial denervation of the rectum might be responsible, al None of the clinical, radiologic, or manometric parameters studied were found to be predictive of functional outcome. 12 After anterior resection alone, advocated for many years by the Mayo Clinic group, 13 the recurrence rate was 9 percent, and the continence status worsened in 22 percent. Twenty-nine percent of patients experienced a complication. Results of abdominal resection rectopexy appear to equal those achieved by rectopexy alone with regard to the recurrence rate. 14 Resection of the redundant sigmoid reduces the risk of severe constipation clinically and on the basis of colonic markers studies 15 but increases the magnitude of the procedure. Effects on continence are conflicting. In one study by Sayfan et aL, ~6 continence was not impaired by sigmoidectomy even in the elderly. In another study by Mc Kee et al.,15 postoperative incontinence in 33 percent of the patients was the major disability. Given this risk, the author advocated concomitant pelvic floor repair. All abdominal procedures are prone to correct the loss of sacral attachments of the rectum and deep peritoneal reflection. Concomitant resection provides adequate rectosigmoid shortening; however, they have two drawbacks that might account for the functional results: 1) they entail a rectal mobilization with subsequent changes in motility and sensation and 2) pelvic floor repair is presumably less effective from above than from below.
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Perineal repair has traditionally b e e n considered the preferred procedure in the elderly and debilitated patients unfit for an abdominal approach. The operation is safe, anesthetic risk is low, and recovery is short, but it has been reported to entail poorer anatomic and functional outcome. Perineal rectosigmoidectomy is the procedure of choice at the University of Minnesota for elderly and high-risk patients. In a recent study of 104 patients with a mean follow-up of 12 months, the recurrence rate was 10 percent, but only 46 percent of incontinent patients improved. 17 There is a wide discrepancy in the reported recurrence rate of that procedure ranging from 0 to 60 percent. 5 In the series by Watts et al., ~4 functional results were dismal. Only 6 percent of patients improved their level of continence, whereas 22 percent were made worse. Presumably, reduction of capacity and replacement of the rectum by noncompliant sigmoid in addition to sensory changes and damage to the internal sphincter could account for impairment of continence. However, recent studies have stressed a very low recurrence rate and a dramatic improvement of continence with addition of a concomitant preanal and postanal levatorplasty.18, 19 The innovative extended Delorme's procedure herein described has two theoretic advantages over perineal proctectomy: it avoids the hazards of a coloanal anastomosis, and respects the internal sphincter innervation, rectal sensitivity, and compliance. The original Delorme's procedure was only able to correct abnormal length of the rectum. In our experience, the best results were obtained in younger patients (mean age, 55 years) with good pelvic floor musculature. On the other hand, in elderly patients (mean age, 82 years) with a weak pelvic floor, a gaping anus, and a sliding hernia of the cul-de-sac, results were disappointing, with a 21 percent recurrence rate. In that group of patients, the principles of groin hernia repair must be applied, i.e., resection of the sac and parietal repair by levatorplasty along with correction of the abnormal length and loss of attachment of the rectum by mucosectomy and posterior rectopexy. This complete posterior perineorrhaphy is possible using a transrectal approach without separate perineal incisions. The transrectal hernia of the cul-de-sac is a prominent feature discovered in 75 percent of female patients; however, it is rather unc o m m o n in males (25 percent). Absence of excision is a main cause of recurrence. What would be the virtue of a hernia repair leaving the sac?
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The significant rise in complication rate (22 percent), mostly stenosis, was related to mucosal excision excessive in length at the onset of our experience. Stenosis is currently avoided by limited mucosal stripping not exceeding the apex of the prolapse. With regard to correction of the prolapse, a significant improvement has b e e n demonstrated b y the present operation. A 5 percent recurrence rate with a mean follow-up of 18 months was within the range and c o m p a r e d favorably with figures reported for abdominal rectopexy. However, long-term results cannot be properly assessed. With regard to functional outcome, 69 percent of incontinent patients improved, with return of full continence in 44.5 percent. Anorectal sensation, initially disturbed, improved in the postoperative period to a normal level after two or three weeks. No patient complained of defecation disturbances or worsening of incontinence. Satisfactory results were obtained in patients with obstructed defecation. When comparing original vs. extended operation, functional results were not significantly different. This finding confirms that restoring normal anorectal anatomy, allowing a normal function, is the most important factor. In that respect, the extended perineal repair has a better restoring score than abdominal procedures.
CONCLUSIONS It can be assessed from this report that 1) functional results of Delorme's procedure compare favorably with abdominal procedures in terms of restoration of continence, 2) unlike abdominal rectopexy, Delorme's procedure has no adverse effects on bowel habits, and 3) an extended procedure, allowing a complete pelvic floor repair, is possible by a transrectal approach without separate incisions or coloanal anastomosis with a low recurrence rate. Our initial tendency was to select Delorme's procedure for patients d e e m e d at risk for a more extensive procedure. Our current policy based on primacy of functional outcome is to consider the extended Delorme's procedure as the first choice in virtually all patients presenting with rectal prolapse. Abdominal rectopexy, which is in essence unnatural by fastening, encircling, suspending, or denervating a mobile and sensitive viscera, is reserved for postoperative failure if general conditions permit. In most cases, procidentia is a c o m p o n e n t of a plurifactorial disorder of the pelvic floor in elderly w o m e n amenable to perineal repair that avoids physiologic disturbances of the rectum.
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Exceptionally, procidentia is a basic disorder of the rectum and the sporadic result of straining at stools particularly in young m e n with a high level rectal intussusception above a stiff pelvic floor. In these particular instances, transabdominal treatment must be considered. We n o w perform a posterior rectopexy to the sacral fascia, according to Wells, with absorbable mesh (Vicryl| in association with sigmoidectomy. Rectal mobilization is only carried out posteriorly, leaving the p o u c h of Douglas and lateral ligaments intact. ACKNOWLEDGMENT The authors thank Aymar Lechaux, M.D., for reviewing the manuscript. REFERENCES 1. Lechaux JP, Johann M. L'operation de Delorme dans le traitement du prolapsus rectal. Presse M~d 1984;13:21920. 2. Lechaux JP. Traitement chirurgical du prolapsus rectal complet de l'adulte-Edition techniques-Encycl. M~d. Chir. (Paris-France), Techniques Chirurgicales-G~n~ralites-Appareil Digestif, 40710, 1992:14. 3. Rogers J, Jeffery PJ. Post anal repair and intersphincteric Ivalon sponge rectopexy for the treatment of rectal prolapse. Br J Surg 1987;74:384-6. 4. Uhlig BE, Sullivan ES. The modified Delorme operation: its place in surgical treatment for massive rectal prolapse. Dis Colon Rectum 1979;22:513-21. 5. Watts JD, Rothenberger DA, Goldberg SM. Rectal prolapse: treatment. In: Henry MM, Swash M, eds. Coloproctology and the pelvic floor: pathophysiology and management. London: Butterworths, 1985:308-39. 6. Williams JG, Wong WD, Jensen L, Rothenberger DA, Goldberg SM. Incontinence and rectal prolapse: a prospective manometric study. Dis Colon Rectum 1991;34: 209-16. 7. Holmstr6m B, Brod~n G, Dolk A. Results of the Ripstein operation in the treatment of rectal prolapse and internal rectal procidentia. Dis Colon Rectum 1986;29:845-8. 8. 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. 9. Mann VC, Hofman C. Complete rectal prolapse: the anatomical and functional results of treatment by an extended abdominal rectopexy. BrJ Surg 1988;75:34-7. 10. 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. 11. Delemarre JB, Gooszen HG, Kruyt RH, et al. The effect of posterior rectopexy on fecal continence. Dis Colon Rectum 1991;34:311-6.
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12. Sainio AP, Voutilainen PE, Husa M. Recovery of anal sphincter function following transabdominal repair of rectal prolapse: cause of improved continence? Dis Colon Rectum 1991;34:816-21. 13. Schlinkert RT, Beart RW, Wolff BG, Pemberton JH. Anterior resection for complete rectal prolapse. Dis Colon Rectum 1985;28:409-12. 14. Watts JD, Rothenberger DA, Buls JG, Goldberg SM, Nivatvongs S. The management of procidentia: 30 years experience. Dis Colon Rectum 1985;28:96-102. 15. Mc Kee RE, Lauder JC, Poon FW, Aitchison MA, Finlay IG. A prospective randomized study of abdominal rectopexy with and without sigmoidectomy in rectal prolapse. Surg Gynecol Obstet 1992;174:145-8.
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16. Sayfan J, Pinho M, Mexander-Williams J, Keighley MR. Sutured posterior abdominal rectopexy with sigmoidectomy compared with Marlex| rectopexy for rectal prolapse. BrJ Surg 1990;77:143-5. 17. Williams JG, Rothenberger DA, Madoff RD, Goldberg SM. Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy. Dis Colon Rectum 1992;35:830-4. 18. 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. 19. Prasad ML, Pearl RK, Abcarian H, et al. Perineal proctectomy, posterior rectopexy, and post anal levator repair for the treatment of rectal prolapse. Dis Colon Rectum 1986;29:547-52.