Complete Rectal Prolapse Research Articles

Cauterization-plication operation in the treatment of complete rectal prolapse.

The current communication presents a simple technique for treatment of complete rectal prolapse (CRP). The study included 28 patients presenting with CRP (mean age, 36.4 years; 4 children 2-12 years; 17 female and 11 males). Fourteen patients had fecal incontinence. With the patient under general anesthesia in lithotomy position, the prolapsed rectum was pulled outside the anal canal, the mucosa was cauterized in vertical lines and the exposed muscle layer was plicated by 2/0 coated Vicryl sutures. Posterior levatorplasty was done in 14 adult patients in whom the length of prolapsed segment was more than 10 cm and who were incontinent due to a wide levator hiatus. The postoperative follow up was 31.6+/-14.8 months (mean+/-SD). Five had postoperative mucosal prolapse and one had recurrence 3 months of operation. Mucosal plication was performed for the five patients and the operation was redone for the recurrent patient. Fecal impaction, stricture and fistula formation were not encountered. The technique is simple, easy and with minimal complications.

Preserving the superior rectal artery in laparoscopic [correction of laparoscopis] anterior resection for complete rectal prolapse.

Anterior resection for the treatment of full thickness rectal prolapse has been around for over four decades. 1 However, its use has been limited due to fear of anastomotic leakage and related morbidity. It has been shown that high anterior resection is preferable to its low counterpart as the latter increases complication rates. 2 Although sparing the inferior mesenteric artery in sigmoid resection for diverticular disease has been shown to decrease leak rates in a randomized setting, 3 vascular division is current practice. We shall challenged this current practice of dividing the mesorectum in anterior resection for complete rectal prolapse developing a technique that allows the preservation of the superior rectal artery.

The value of posterior levator repair in the treatment of anorectal incontinence due to rectal prolapse--a clinical and manometric study.

When treating a complete rectal prolapse, the most important objective is elimination of the prolapse. In addition, restoration of sufficient anorectal continence is extremely important for the patients. We examined the value of posterior levator repair with respect to stabilization of the pelvic floor and to improvement in anorectal incontinence. In patients with disabling anorectal incontinence, a posterior levatorplasty can be concomitantly performed during operative removal of the prolapse. To facilitate evaluation of the operative results, we implemented a scoring system to judge the patients' subjective symptoms of incontinence; in addition, we performed manometric measurements of resting and squeezing pressures of the anal sphincter to objectify the anorectal incontinence. From 1991 to 1997, 84 patients (mean age 65+/-10 years, 38-91 years; 79 women, 5 men) with complete rectal prolapse and severe incontinence were operatively treated; corresponding follow-ups were done. The following procedures were performed: Frykmann-Goldberg, 28 patients; Wells, 18 patients; Ripstein, 22 patients; and perineal proctectomy, 16 patients. Incontinence for liquid and solid stools was present in all of these patients. Posterior levatorplasty was implemented in 38 patients, and in this group we found significantly better postoperative results, both clinically and in the manometric measurements. Continence was improved by 84% in the group with levatorplasty, but improvement was only 67% in the other group (P<0.05). The incontinence score decreased significantly in the group with levatorplasty (preoperative 16.4+/-3.1, postoperative 9.3+/-4.5, P<0.05, vs the other group with preoperative 15.6+/-4.2, postoperative 11.5+/-5.1). Manometric observations in the group with levatorplasty demonstrated 55% improvement in resting pressure (preoperative 29+/-17 cm H2O, postoperative 45+/-21 cm H2O, P<0.05) and 40% improvement in squeezing pressure (preoperative 61+/-25 cm H2O, postoperative 85+/-31 cm H2O, P<0.05). In the group without levatorplasty, resting and squeezing pressure improved only by 20% (resting pressure: preoperative 32+/-16 cm H2O, postoperative 38+/-18 cm H2O; squeezing pressure: preoperative 64+/-29 cm H2O, postoperative 75+/-26 cm H2O). Posterior levatorplasty is an easy and efficient operative procedure which facilitates an improvement in anorectal continence. There are no apparent disadvantages. For this reason, levatorplasty can be part of operative procedures implemented in the treatment of a complete rectal prolapse accompanied by disabling anorectal incontinence.

完全直腸脱に対するＤｅｌｏｒｍｅ手術後の排便機能

完全直腸脱に対してDelorme手術を行い,術後6カ月以上経過した12例を対象に術前後の排便機能を評価した.平均年齢は75歳,男女比は3:9であった.術後観察期間の中央値は2年2カ月であり,この間に再発を1例認めた.便失禁は7例中4例で改善し,術後排便困難をきたした例はなかった.便意と便とガスの識別の回復は各々60%,33%でみられた.肛門内圧検査では肛門管最大静止圧と最大随意収縮圧は術後有意に高値となった.直腸感覚検査では便意発現最小量と最大耐容量は術後有意に低値になった.このような括約能と直腸感覚の改善により便失禁の改善が得られ,排便困難症の防止になったと推察された.

Perineal rectosigmoidectomy: An effective approach for the repair of complete rectal prolapse

The results of five consecutive perineal rectosigmoidectomies were reviewed to evaluate the role of this approach for complete rectal prolapse. There were two male and three female patients, with a median age of 75 years (range 45–82 years). On average, 23.6 cm (range 15–35 cm) of sigmoid colon and rectum was resected. There was no operation‐related mortality. One patient developed postoperative chest infection and another acute retention of urine. No recurrence of the prolapse was detected during a median follow‐up period of 25 months (range 6–42 months). Perineal rectosigmoidectomy is an effective and the least invasive procedure for complete rectal prolapse. It is the preferred approach for patients who have had multiple previous abdominal operations and for the frail elderly patient in whom, particularly, constipation is a major associated feature.

Transsacral rectopexy for recurrent complete rectal prolapse.

The aim of this study was to examine the functional outcome of transsacral rectopexy performed with Dexon mesh for recurrent complete rectal prolapse. Anorectal function was assessed by anorectal manometry and defecography, before and from 1 year after surgery in five patients who were followed up for 1-3 years. The fecal incontinence score recovered from a preoperative mean score of 3.8 to a postoperative mean score of 1.2, and constipation was improved in four patients (80%). The straining anorectal angle (S-ARA), measured by defecography, improved from a preoperative value of 120.6 degrees +/- 6.9 degrees to a postoperative value of 98.5 degrees +/- 3.5 degrees (P < 0.05), and the perineal descent (PD) improved from a preoperative value of 16.2 +/- 2.5 cm to a postoperative value of 8.1 +/- 1.3 cm (P < 0.05). The maximal resting pressure (MRP) increased from a preoperative value of 20.5 +/- 3.7 cmH2O to a postoperative value of 40.5 +/- 4.8 cmH2O (P < 0.05). These findings indicate that transsacral rectopexy with Dexon mesh can achieve good control of recurrent complete rectal prolapse.

SURGERY FOR COMPLETE RECTAL PROLAPSE: A SIMPLIFIED APPROACH

Complete prolapse of rectum (procedentia) is said to occur when the full circumference of the rectal wall is everted through the anus. Numerous techniques have been developed in order to treat procedentia, an uncommon pathology that is managed occasionally by the general surgeon. A simple, safe and effective procedure is recommended for surgeons who treat procedentia recti once in a while. We describe a simple rectopexy procedure which has been used effectively in 38 patients in the last 10 years. In this prospective study we evaluated the results which are comparable to other standard operative techniques in terms of morbidity, anatomic correction and bowel function. This technique is based on sound scientific principles in the aetiopathogenesis of rectal prolapse. This procedure obliterates the abnormally deep cul de sac of rectovesical pouch and supports the anterior rectal wall by suturing it to the bladder base to prevent initiation of sliding herniation of anterior rectal wall, which causes procedentia recti. Posterior dissection fibrosis fixes the posterior rectal wall to the sacrum after healing and restores the normal posterior curve of rectal canal and corrects the pathogenic straightening of rectum which promotes prolapse. Minimal mobilization of rectum is done and lateral ligaments are not dissected hence all attendant complications e.g. impotence, urinary incontinence, constipation etc are avoided. Simplicity, effectiveness, safety and non requirement of prosthetic material makes it an ideal operation suitable for a general surgeon working in the periphery.

The effect of abdominal rectopexy with mesh on anal sphincter and bowel function in patients with complete rectal prolapse; special reference to age of patient

The main source of concern in patients with rectal prolapse is usually incontinence and constipation developing post-operatively. It has been claimed that sphincter pressures improve only after non-implant surgery. The aim of this study was to assess our own results after mesh rectopexy. We reviewed the results in 50 patients on whom posterior abdominal Marlex mesh rectopexy for complete rectal prolapse had been performed. These patients underwent pre- and post-operative anal manometry. Sixteen of them also underwent colon transit time study before and after the operation. They were followed clinically for a median of 5 months. Twenty-two of the 38 patients (58%) with preoperatively defective anal control regained full continence. Resting anal canal pressures improved significantly after surgery in all cases (P=0.001), including those who regained full continence (P=0.005). The change in continence in all patients correlated inversely with the preoperative (r=-0.43, P=0.003) and post-operative (r=-0.40, P=0.005) resting anal pressures. The change in resting anal pressures after surgery was significantly better in patients under 40 years of age (mean 19 cmH2 O) than in those 40 years or older (mean 4 cmH2 O) (P=0.01). All four preoperatively incontinent patients regained full continence in the younger group as opposed to only 50% (17/34) in the older group. Colon transit time normalized in three of the four patients with preoperatively slow transit time and five patients with preoperatively normal transit time developed slow transit. Internal sphincter pressures do improve after mesh rectopexy for rectal prolapse, and the change also correlates with the improvement in continence. Internal sphincter function and continence recover better in younger patients.

Surgical treatment of complete rectal prolapse: results of abdominal and perineal approaches.

This retrospective study reports the results of our 5-year experience in the diagnosis and treatment of rectal prolapse with fecal incontinence by the abdominal (laparotomy or laparoscopy) and perineal approaches. Twenty-five patients (group A; 22 women and 3 men; mean age 57.3 years; range 22-76 years) were operated on by the abdominal approach and ten (group B; 8 women and 2 men; mean age 68.9 years; range 58-84 years) by the perineal approach. All patients were evaluated by clinical examination, proctosigmoidoscopy, pancolonic transit time, dynamic defecography, anorectal manometry, and anal electromyography preparatory to surgery. In patients of group A, we performed an abdominal rectopexy in 19 cases (7 by laparoscopy) and in the remaining 6 cases, a sigmoid resection-rectopexy (3 of which were by laparoscopy). All patients of group B were treated by a perineal operation using Delorme's mucosectomy in 4 cases and Altemeier's rectosigmoidectomy with total perineoplasty in 6 cases. The mean follow-up was 38.8 months in group A and 25.7 months in group B. The postoperative complication rate was 8% (two cases) in group A, whereas no significant complications occurred in group B. Dyschezia and fecal incontinence improved significantly in both groups (P < 0.05 in group A and P < 0.005 in group B), whereas anoperineal pain was not significantly reduced. At 1-year follow-up, the recurrences rates were 8% in group A and 30% in group B. Rectopexy or resection-rectopexy proved to be a safe and effective procedure for external prolapse, without a discernible difference between the laparotomic and laparoscopic techniques. In selected cases, the perineal approach gives good results regarding fecal incontinence without complications, even if in these patients, the likelihood of recurrence is high.

Functional results of operative treatment of rectal prolapse over an 11-year period: emphasis on transabdominal approach.

A variety of surgical procedures have been developed to treat rectal prolapse, but there is still no consensus on the operation of choice. The aim of this study was to evaluate the functional results of operative treatment of rectal prolapse during an 11-year period in our department. All patients treated for complete rectal prolapse during an 11-year period, from 1985 to 1995, in a single university hospital were included. Of the 123 patients, 22 were men, and the mean age was 59 (range, 15-88) years. The medical records of all patients were reviewed retrospectively, and a questionnaire on bowel symptoms before and after surgery was sent to all 95 living patients. The majority of the procedures (91 percent) were performed by abdominal approach, and the most frequently used open technique was posterior rectopexy with mesh (78 percent). Of the incontinent patients, 35 (63 percent), all those less than 40 years of age and 64 percent of those 40 years or older, were continent postoperatively (P = 0.0001) after a median follow-up of five (range, 1-72) months. According to the questionnaire, after a median follow-up of 85 (range, 16-144) months, only 38 percent of the incontinent patients in the mesh or suture group, 78 percent of patients less than 40 years of age (n = 18), and 52 percent of those 40 years or older (n = 47) claimed to be continent postoperatively. The proportion of patients with constipation was greater after the operation than preoperatively (P = 0.02) and more patients used medication for constipation after than before the operation (P = 0.0001). The overall complication rate was 15 percent, and the mortality rate was 1 percent (1/123). In the mesh or suture group there were 6 (6 percent) recurrent complete prolapses and 11 (12 percent) mucous prolapses. Posterior rectopexy with mesh gave good results in our hands. Older age and longer follow-up seem to have a negative effect on the functional outcome of the operation and on the recurrence rate.

Complete rectal prolapse: evolution of management and results.

Optional treatment for complete rectal prolapse remains controversial. We reviewed our experience over a 19-year period to assess trends in choice of operation, recurrence rates, and functional results. We identified 372 patients who underwent surgery for complete rectal prolapse between 1976 and 1994. Charts were reviewed and follow-up (median, 64: range, 12-231 months) was obtained by mailed questionnaire (149 patients; 40 percent) and telephone interview (35 patients; 9 percent). Functional results were obtained from 184 responders (49 percent). Median age of patients was 64 (11-100) years, and females outnumbered males by nine to one. One-hundred and eighty-eight patients (51 percent) were lost to follow-up; 183 patients (49 percent) underwent perineal rectosigmoidectomy, and 161 patients (43 percent) underwent abdominal rectopexy with bowel resection. The percentage of patients who underwent perineal rectosigmoidectomy increased from 22 percent in the first five years of the study to 79 percent in the most recent five years. Patients undergoing perineal rectosigmoidectomy were more likely to have associated medical problems as compared with patients undergoing abdominal rectopexy (61 vs. 30 percent, P = 0.00001). There was no significant difference in morbidity, with 14 percent for perineal rectosigmoidectomy vs. 20 percent for abdominal rectopexy. Abdominal procedures were associated with a longer length of stay as compared with perineal rectosigmoidectomy (8 vs. 5 days, P = 0.001). Perineal procedures, however, had a higher recurrence rate (16 vs. 5 percent, P = 0.002). Functional improvement was not significantly different, and most patients were satisfied with treatment and outcome. We conclude that abdominal rectopexy with bowel resection is associated with low recurrence rates. Perineal rectosigmoidectomy provides lower morbidity and shorter length of stay, but recurrence rates are much higher. Despite this, perineal rectosigmoidectomy has appeal as a lesser procedure for elderly patients or those patients in the high surgical risk category. For younger patients, the benefits of perineal rectosigmoidectomy being a lesser procedure must be weighed against a higher recurrence rate.Patient satisfaction]

Sigmoid Colon Cancer Presenting as Complete Rectal Prolapse: Report of a Case

Sigmoid Colon Cancer Presenting as Complete Rectal Prolapse: Report of a Case

Laparotomic vs. Laparoscopic Rectopexy in Complete Rectal Prolapse

Aim: The aim of this study was to compare the functional and clinical results of laparotomic and laparoscopic rectopexy in 2 homogeneous groups of patients with complete rectal prolapse and fecal incontinence. Methods: Between January 1989 and December 1997, twenty-three patients underwent abdominal rectopexy. Thirteen patients (group A, 12 females and 1 male, mean age 57.3, range 22–76 years), and 10 patients (group B, 10 females, mean age 52.3, range 26–70 years) were submitted respectively to either Wells laparotomic or laparoscopic rectopexy by the same surgical team using the same surgical technique and materials. Before the operation a detailed clinical history was collected, and the patients were studied by inspection and digital examination of the anorectum, proctosigmoidoscopy, pancolonic transit time, dynamic defecography, anorectal manometry and anal electromyography. After the operation all patients underwent perineal physiotherapy, external electric stimulation, and perineal biofeedback. Mean follow-up was 37.1 (range 6–90) months in group A and 25.7 (range 6–49) months in group B. Values were compared by χ², Mann-Whitney U, and Wilcoxon tests as appropriate. Differences were considered significant at p < 0.05. Results: In both groups dyschezia and fecal incontinence improved significantly (p < 0.05) after the operation. The basal pressure of the anal sphincter, squeezing pressure and rectoanal reflex improved without significance, and anal-perineal pain was not significantly reduced. In group B the postoperative hospital stay was lower than in group A, with a reduction in costs. Conclusion: Laparoscopic Wells rectopexy has the same clinical and functional results as laparotomic rectopexy, but with a shorter postoperative hospital stay and lower costs.

Delorme's Procedure for Complete Rectal Prolapse of Patients with Mental Disorders: Report of Three Cases

Delorme's Procedure for Complete Rectal Prolapse of Patients with Mental Disorders: Report of Three Cases

Functional results after laparoscopic rectopexy for intussusception and complete rectal prolapse

Functional results after laparoscopic rectopexy for intussusception and complete rectal prolapse

Comparison of laparoscopic rectopexy with open technique in the treatment of complete rectal prolapse: clinical and functional results.

The aim of this retrospective study was to compare the functional and clinical results of laparoscopic rectopexy with those of the open technique in two similar groups of patients with complete rectal prolapse and fecal incontinence. Between November 1992 and June 1997, 21 patients underwent abdominal rectopexy. Thirteen patients (group A: 12 women and 1 man, mean age 52.9 years, range 28-70) and 8 patients (group B: 8 women, mean age 58.2 years, range 20-76) were submitted to Well's rectopexy by the open technique and the laparoscopic approach, respectively, without division of the lateral rectal ligaments. Assignment to each group was done randomly. Before the operation, a detailed clinical history was taken, and patients were studied with inspection and digital examination of the anorectum, proctosigmoidoscopy, determination of pancolonic transit time, dynamic defecography, anorectal manometry, and anal electromyography. After the operation, all patients underwent perineal physiotherapy, external electric stimulation, and perineal biofeedback. The mean follow-up time was 29.5 months (range 6-54) in group A and 25.7 months (range 8-45) in group B. Values were compared by chi-square, Mann-Whitney U, and Wilcoxon tests, as appropriate; differences were considered significant at p < 0.05. In both groups, dyschezia and fecal incontinence improved significantly (p < 0.05) after the operation. Basal pressure of anal sphincter, squeezing pressure, and rectoanal reflex improved without significance, whereas anoperineal pain was not significantly reduced. In group B, the postoperative hospital stay was shorter than in group A, with a marked reduction of costs. Laparoscopic Well's rectopexy has the same clinical and functional results as the open technique, with a shorter postoperative hospital stay and lower costs.

Transsacral Rectopexy for Complete Rectal Prolapse.

A prospective study was carried out to analyze the clinical and functional results of transsacral rectopexy with a DEXON mesh in the elderly or poor risk patients with complete rectal prolapse. Six patients with complete rectal prolapse were operated from 1994 to 1996. All patients could be traced for examination with anorectal manometry and defecography. None of the patients had recurrence for the longest three years. In postoperative clinical symptoms, fecal incontinence score recovered from the preoperative mean score of 3.8 to the postoperative 1.2 and constipation was improved in 4 out of 5 cases (80.0%). Straining anorectal angle (S-ARA) by defecography improved from the preoperative value of 120.6 +/- 6.9 degrees to the postoperative value of 98.5 +/- 3.5 degrees (p < 0.05) and the perineal descent (PD) improved from the preoperative value of 16.2 +/- 2.5 cm to the postoperative value 8.1 +/- 1.3 cm (p < 0.05). Maximal resting pressure (MRP) increased from the preoperative value of 20.5 +/- 3.7 cmH2O to the postoperative value of 40.5 +/- 4.8 cmH2O (p < 0.05). Transsacral rectopexy with DEXON mesh for complete rectal prolapse is useful as this technique is simple to conduct, can be applied to the elderly or poor risk patients, replaces rectal prolapse, improves defecation troubles and recovers fecal incontinence.

Long-term results of suture rectopexy in patients with fecal incontinence associated with incomplete rectal prolapse.

Suture rectopexy is the recommended therapy for complete rectal prolapse that is associated with fecal incontinence. It has been suggested that correction of an incomplete rectal prolapse is also worthwhile for patients with fecal incontinence. Aims of this study were 1) to evaluate the clinical outcome of suture rectopexy in a consecutive series of patients with incomplete rectal prolapse associated with fecal incontinence, and 2) to compare these results with those obtained from patients with complete rectal prolapse. Between 1979 and 1994, suture rectopexy was performed in 13 incontinent patients (3 males; median age, 65 (range, 45-77) years) with incomplete rectal prolapse (Group I) and in 24 incontinent patients (21 females; median age, 71 (range, 24-86) years) with complete rectal prolapse (Group II). After a median follow-up of 67 months, continence was restored in 5 of 13 (38 percent) patients with incomplete rectal prolapse and in 16 of 24 (67 percent) patients with complete rectal prolapse. In both groups, all male patients became continent. For the majority of incontinent patients with incomplete rectal prolapse, a suture rectopexy is not beneficial. The clinical outcome of this procedure is only good in incontinent patients with complete rectal prolapse. Based on these data, it is questionable whether incomplete rectal prolapse plays a causative role in fecal incontinence.

Management of recurrent rectal prolapse.

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. 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. 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. 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.

Surgical treatment of recurrent complete rectal prolapse

Complete recurrent rectal prolapse (RRP) after initial prolapse surgery is well described. Our aim was to examine the possible causes for RRP, to learn of the operations performed most frequently, and to examine the outcome following recurrence surgery. Patients with RRP were reviewed retrospectively from 1963 to 1993. A total of 24 patients (19 females) had RRP. Of these, 29 operations were performed; three patients had 2 RRP operations, and one patient had 3 RRP operations. Median age was 56 (range, 18-88) years. Median follow-up and median duration to recurrence were 6.75 (range, 0.08-17) years and 2 (range, 0.1-29) years. One patient had RRP at the end of the follow-up period. RRP occurred after 15 abdominal and 9 perineal operations. Treatment for RRP included 25 abdominal and 4 perineal operations. Causes for RRP were identified in 41 percent of cases and was most often attributable to problems with the mesh following the Ripstein procedure. Preoperative incontinence and constipation were largely unchanged by RRP operation. RRP occurred most commonly because of problems with the mesh, but no etiologic factor was found in the majority of patients. Abdominal operations were performed more frequently than perineal approaches for RRP. Elimination of prolapse can be obtained, but bowel dysfunction still remains in 60 percent of patients.