Stuhlinkontinenz und Rektumprolaps – Operationen zur Wiederherstellung oder Verbesserung der Kontinenz

Abstract

Fecal Incontinence and Rectal Prolapse – Surgical Procedures to Restore or Improve Continence Full-thickness rectal prolapse and fecal incontinence are benign diseases of the elderly, associated with paramount distress. In cases of rectal prolapse the affliction can solely be alleviated by surgery, whereas in cases of fecal incontinence without prolapse operative procedures are only indicated when conservative therapy has failed. With respect to the elevated risk of surgery in geriatric patients, the indication for benign conditions to operate has to be considered particularly carefully. The same applies to the selection of the type of procedure. In the presence of full-thickness rectal prolapse, resectional rectopexy (open or by laparoscopy) is without doubt the procedure with the lowest rate of recurrence. High age, polymorbidity, and poor general state are factors that often preclude procedures by laparotomy. Instead, there is a need for other surgical methods that possibly require regional anesthesia only. In the present series 38 patients underwent altogether 44 perineal Delorme’s operations, among them 34 patients over 60 years of age. Continence was improved in 62%, the rate of recurrence was 43%. In 53 cases of persistent fecal incontinence without rectal prolapse but with a proven sphinter defect and pathologically reduced pressures in anal manometry, we performed altogether 57 sphincter repairs. In our patients, conservative therapy had been amply applied and proven as ineffective or unsatisfactory. In the 25 patients, aged over 60 years, continence was improved by surgery in 80%. The best results – improvement of continence in 90% – were achieved in the subgroup of patients with a postpartal sphincter defect. In the majority of cases perineal procedures for rectal prolapse and reconstructions of the defect anal sphincter are apt to improve continence. But high age and the often preexistent debility of the pelvic floor muscles rarely permit a reconstitution of normal morphology and sphincter function that is as perfect as durable. However, as these operations carry a low morbidity and virtually no mortality, their generous application is justified with the purpose to improve the quality of life even in very progressed age. Only in 1 patient with recurring rectal prolapse a terminal Hartmann’s colostomy had to be established. This corroborates that also in geriatric patients a stoma is the very last issue that is only to be recurred to when patients explicitly ask for it.