Tech Coloproctol (2011) 15 (Suppl 1):S25–S28 DOI 10.1007/s10151-011-0747-8
Surgical management of rectal prolapse A. Michalopoulos • V. N. Papadopoulos • S. Panidis • S. Apostolidis A. Mekras • V. Duros • A. Ioannidis • G. Stavrou • G. Basdanis
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Published online: 2 September 2011 Ó Springer-Verlag 2011
Abstract Purpose Rectal prolapse is uncommon; however, the true incidence is unknown because of underreporting, especially in the elderly population. Full-thickness rectal prolapse, mucosal prolapse and internal prolapse are three different clinical entities, which are often combined and constitute rectal prolapse. The aim of the study is to present our experience in the surgical management of rectal prolapse. Methods In a 6-year period (2004–2010), 27 patients were surgically treated for rectal prolapse. The majority of patients were women (25 women, two men) and their mean age was 72.36 years. The operations performed were two Delorme’s procedures, five STARR (Stapled TransAnal Rectal Resection), 14 Wells procedures, two Wells combined with Thiersch, one Altemeier, one sigmoid resection combined with Wells and two Thiersch. Results An emergency sigmoidostomy was performed on a patient after Wells operation due to obstructive ileus. One death occurred on the 5th postoperative day due to pulmonary embolism. Two recurrences observed 8 months postoperatively, one in a patient after STARR operation
A. Michalopoulos V. N. Papadopoulos (&) S. Panidis A. Mekras V. Duros A. Ioannidis G. Stavrou G. Basdanis First Propedeutic Surgical Department, Aristotle’s University of Thessaloniki, A.H.E.P.A. Hospital, T. Oikonomidi 21, Kalamaria, 551 31 Thessaloniki, Greece e-mail:
[email protected] S. Apostolidis Department of Anatomy, Medical School, Aristotle’s University of Thessaloniki, A.H.E.P.A. Hospital, T. Oikonomidi 21, Kalamaria, 551 31 Thessaloniki, Greece
and one in a patient after Thiersch technique. The great majority of patients are completely relieved of symptoms. Conclusions The application of different modalities in the treatment of rectal prolapse is attributed to the fact that cause, degree of prolapse and symptoms, vary from one patient to another. Successful approach depends on many factors, including the status of a patient’s anal sphincter muscle before surgery, whether the prolapse is internal or external and the overall condition of the patient. Keywords
Rectal prolapse STARR Wells Thiersch
Introduction Rectal prolapse is defined as a protrusion of all rectal layers through the anal sphincters. The underlying cause remains unclear. It affects mostly the elderly and especially women in a 6:1 ratio. Some series incriminate a multiparous history while others question that [1] in most cases there is history of chronic constipation or intense effort during defecation. The leading symptom is the protrusion itself; other symptoms that might coexist include constipation, sensation of incomplete evacuation, rectal bleeding (20–60% of patients), rectal pain (12–70% of patients) incontinence (liquids, mucous or faeces), urgency and tenesmus. Although constipation and straining may contribute to the development of rectal prolapse, simply correcting these problems may not improve the prolapse once it has developed. More than 300 surgical procedures have been proposed over the years. These include transabdominal, perineal or transsacral techniques, with the use of prosthetic material or not, complex and simpler ones. An abdominal repair may be approached laparoscopically in selected patients. The vast number of procedures points out
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the inability to propose the ideal therapeutic modality to cure this disorder. The decision to abdominal or rectal surgery takes into account many factors, including age, physical condition and the extent of prolapse.
after Thiersch technique. The great majority of patients are completely relieved of symptoms during the first 3 months of the follow-up. Ten patients occasionally used laxatives to avoid chronic constipation and straining.
Methods
Discussion
During the period 2004–2010, 27 patients were referred and operated for rectal prolapse in our department. Twentyfive were women (91%) and two men (9%). The mean age was 72.4 (range 64–85) years. Diagnosis achieved with a careful history and a complete anorectal examination. To evaluate the prolapse, patients asked to ‘‘strain’’ as if having a bowel movement. Colonoscopy was also performed in all patients to exclude other underlying pathologies. In all patients, the symptoms persisted for more than 12 months. Most common symptoms were feeling of incomplete evacuation, painful effort, defecation assisted by the patient, fragmented evacuation, incontinence, mild bleeding and evacuation obtained by use of enemas. Concerning the gynaecological history, nine women had vaginal deliveries and six had a cesarian one. Two women had undergone a hysterectomy for leiomyomas. A solitary rectal ulcer was found in another woman and a polyp in one male patient. The polyp was excised during rectoscopy and the pathological examination revealed a villous adenoma. All patients underwent mechanical bowel preparation with two fleet enemas the night before the operation and received a single shot of cefuroxime 750 mg and metronidazole 500 mg 30 min preoperatively. The operations performed were two rectal mucosectomies and folding of the rectal wall (Delorme), five stapled transanal rectal resections (STARR) (Figs. 1, 2, 3), 14 dorsal rectopexies with the use of a prosthetic material (Wells) (Figs. 4, 5), two Wells combined with a Thiersch loop, one transanal rectosigmoidectomy (Altemeier), one sigmoidectomy combined with rectopexy and two Thiersch (Fig. 6).
There is great controversy regarding the aetiology and pathophysiology of rectal prolapse and rectal intussusception over the past decades. The theories that have evolved incriminate either anatomical factors (concerning the pelvic floor, the sphincteric function, a deep Douglas pouch, etc.) or physiological factors (denervation of the muscles of the pelvic floor) or combination of the above theories. Furthermore, the issue whether surgery can resolve symptoms is controversial. If surgery is indicated, a variety of approaches including transabdominal (rectopexy with/ without resection, with/without mesh) and transrectal procedures such as Delorme’s operation have been proposed [2]. Delorme’s operation has been used in the past for elderly patients with concomitant diseases, which made the transabdominal approach a high risk procedure. Nevertheless, a recent published study presented a lot better results compared with older publications; thus, the
Results The mean hospital stay was 12 days (±3 days). The follow-up time was from 6 months to 5 years. One patient after Wells operation presented with obstructive ileus. A stricture was found in the region of the rectopexy, and an emergency sigmoidostomy was performed. One death occurred on the 5th postoperative day due to pulmonary embolism. Another female patient diseased 3 years later from cardiac arrest. Two recurrences observed 8 months postoperatively, one in a patient after STARR operation and one in a patient
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Fig. 1 Ventral line of sutures in STARR technique
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Fig. 2 Dorsal line of sutures with protection of the vagina in STARR technique
Fig. 3 Firing of the PPH in STARR technique
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recurrence rate reported was 10–13% and there was improvement of continence in 63–87% of patients [3]. Lieberth et al. [4] noted that the results of the procedure in patients under 50 were better. The recurrence rate was 8% in a mean follow-up of 4.1 years and a 15% complication rate. While in the sum of patients of all ages, the recurrence rate was 14.5% and complication rate 25%. The authors’ proposal is that the method should be practised in all ages regardless of the health status. STARR procedure has been another focus of controversial discussion. Recent published studies describe poor functional results, faecal incontinence and complications such as rectal perforation, pelvic sepsis or rectovaginal fistula with the need for faecal diversion. Also previous small series resulted unsatisfactory functional outcome and serious complications that have major impact on the popularity of the procedure. However, according to the German STARR registry study group, STARR seems to be a safe procedure in the majority of cases, with a 21.1% rate of morbidity, but they report conservative management for most cases, without the need for surgical intervention [2]. However, other authors report the need for reinterventions, such as Hartmann procedure, to treat pelvic sepsis following rectal perforation [3]. Transabdominal rectopexy techniques are reported to have success rates higher than 90%, concerning the repair of the prolapse and up to 65% regarding continence. Complications that should be considered due to the prosthetic mesh are sepsis, abscesses, fistulae and rectal stricture, as well as serious constipation which could be attributed to the angle of the redundant sigmoid colon
Fig. 4 Fixation of the mesh on the sacrum in Wells procedure
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of the lateral ligaments. The Cochrane review by Tou et al. [5] concluded that there are not enough data to suggest that either transanal or transabdominal procedures have better results; no differences were observed among various rectopexy techniques; the dissection of the lateral ligaments is associated with less recurrences but higher constipation incidence; laparoscopic rectopexy is associated with less postoperative complications and shorter length of hospital stay and resection rectopexy is accompanied by lower constipation incidence.
Conclusions
Fig. 5 Fixation of the mesh on both sides of the rectum in Wells procedure
The use of different procedures in the treatment of rectal prolapse is attributed to the fact that causes degree of prolapse and symptoms vary from one patient to another. Successful approach depends on many factors, including the status of a patient’s anal sphincter muscle before surgery, whether the prolapse is internal or external and the overall condition of the patient. STARR seems to be a quick and safe procedure, while Wells has higher success rate. Conflict of interest The authors declare that there is no actual or potential conflict of interest in relation to this article.
References
Fig. 6 Tiersch technique
ventral to the fixed rectum, thus causing mechanical obstruction [4]. Other possible cause is the decreased mobility that could be attributed to the fibrosis due to the prosthetic material or the nervous damage due to dissection
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1. Leal VM, Regadas FS, Regadas SM, Veras LR (2010) Clinical and functional evaluation of patients with rectocele and mucosal prolapse treated with transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS). Tech Coloproctol 14:329–335 2. Schwandner O, Fu¨rst A (2010) Assessing the safety, effectiveness, and quality of life after the STARR procedure for obstructed defecation: results of the German STARR registry. Langenbecks Arch Surg 395:505–513 3. Pascual Montero JA, Martı´nez Puente MC, Pascual I et al (2006) Complete rectal prolapse clinical and functional outcome with Delorme’s procedure. Rev Esp Enferm Dig 98:837–843 4. Lieberth M, Kondylis LA, Reilly JC, Kondylis PD (2009) The Delorme repair for full-thickness rectal prolapse: a retrospective review. Am J Surg 197:418–423 5. Tou S, Brown SR, Malik AI, Nelson RL (2008) Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev 4: CD001758
