Delorme Procedure Research Articles

Dynamic MRI (dMRI) as a guide to therapy in children and adolescents with persistent full thickness rectal prolapse: A single centre review

IntroductionFull thickness rectal prolapse (FTRP) tends to be self-limiting in children and is usually managed expectantly. However, it may persist and therefore requires surgical correction. There is no consensus upon operative management, and no one procedure has uniformly good outcomes. The aim of this study was to determine whether pre-operative diagnostic dMRI findings might help identify the operative approach best suited to the anatomical abnormality of the individual child. MethodsA retrospective review of ten children with persistent FTRP who had been evaluated pre-operatively with dMRI between 2002 and 2010 was performed. In this preliminary work, MRI findings were not used to direct surgical management. Data collected included: age at presentation, underlying medical conditions, timing and findings of dMRI (specifically, descent of rectum from pubococcygeal (PC) line on straining), timing and type of surgery, surgical outcomes, and length of follow-up. ResultsTen children (two female) with a median age of 11years 2months (range 8–15years) with FTRP refractory to conservative treatment underwent diagnostic pre-operative dMRI. Median perineal descent from PC line on straining during dMRI was 3.5cm (range 1–4cm). Three of the seven children with severe descent initially underwent a Delorme's procedure, and all required surgical revision. Five with severe descent and one with moderate descent achieved a cure following rectopexy. Two patients with mild descent underwent a Delorme's procedure. One achieved a cure, and the other developed recurrence. Of the ten patients, seven had no prolapse at the last clinic review, and three have persisting symptoms. Median follow-up was 3.5years (range 1–6). ConclusionThe findings from this small study favour rectal suspension techniques for surgical management of moderate to severe perineal descent on dMRI. Delorme's procedure should only be applied to those with mild descent. Pre-operative dMRI assessment may have a potential role in guiding surgical intervention for children. However, future prospective studies will be required to confirm this assertion.

Delorme's Procedure Revisited for an Incarcerated Transverse Loop Colostomy Prolapse Repair

Delorme's Procedure Revisited for an Incarcerated Transverse Loop Colostomy Prolapse Repair

Internal Delorme's procedure for rectal outlet obstruction

The outcome of the internal Delorme's procedure (IDP) for obstructed defaecation was assessed. From October 2001 to March 2009, 167 patients with obstructed defaecation associated with rectal intussusception were operated on. Patients were selected on the basis of validated constipation and continence scores, clinical examination and defaecography. Seventy-six patients were treated by the IDP alone and 91 patients were treated by the IDP with a levatorplasty. Before surgery and after a mean±SD follow up of 3.0±1.5years, patients were assessed using the Cleveland Clinic Incontinence and Constipation Score (CCIS and CCCS), the Obstructed Defecation Score (ODS), faecal urgency and the Patient Assessment of Constipation Quality of Life (PAC-QoL) questionnaire. Seventeen (10.2%) patients developed a postoperative complication including fissure-in-ano (4.2%), proctalgia (3.0%), suture-line dehiscence with stenosis (1.8%) and Clostridium difficile colitis (1.2%). Faecal urgency changed from 22% to 17.6% (P=0.754). Tenesmus fell from 53.9% to 17.1% (P<0.001). The CCCS and the ODS fell by 50% or more in 82.6% and 73.7% of the patients, respectively. The CCIS did not worsen significantly in patients who remained incontinent, and 45.7% of the previously incontinent patients regained normal continence. The CCCS decreased from 11 to 3 (P<0.001) in the patients treated by the IDP and from 12 to 3 (P<0.001) in the patients treated by the IDP with levatorplasty. The overall recurrence rate was 5.4%. The PAC-QoL showed a reduction of anxiety/depression and of physical and psychological discomfort (P<0.001). The IDP is an effective and safe option for rectal outlet obstruction caused by rectal intussusception with excellent function and patient satisfaction.

Surgical Correction Is Ineffective for Improvement of Dyssynergic Defecation in Patients With Rectal Prolapse

Background/AimsThe patients with rectal prolapse suffer from not only a prolapse rectum but also associated dysfunction. However, most surgical techniques are successful regarding the prolapse, but either do not solve or even worsen defecation dysfunction. The purpose of this study was to investigate the functional and physiological results after surgical correction in patients with rectal prolapse.MethodsThis study is a retrospective review of a single-institution experience. Patients with rectal prolapse who underwent anorectal manometry before and after Delorme's procedure were included. The primary outcomes measured were improvement of clinical symptoms and physiologic study.ResultsConsecutive 19 patients with rectal prolapse (17 females, mean age of 68.1 ± 10.8 years) underwent anorectal manometry before and after Delorme's procedure. The two most prevalent symptoms before operation were rectal tenesmus (15/19, 78.9%) and excessive straining (13/19, 68.4%). The two most prevalent symptoms after operation were rectal tenesmus (14/19, 73.6%) and excessive straining (13/19, 68.4%). No significant differences in resting anal pressure, squeezing anal pressure, defecation index, and rectal sense were found postoperatively. However, vector asymmetry index before surgery was higher than that after surgery (35.0 vs. 32.0, P = 0.018). Ten patients (52.5%) had type I dyssynergic defecation before surgery. No improvement of dyssynergic pattern occurred after surgery.ConclusionsIn conclusion, dyssynergic defecation was not improved after reduction of rectal prolapse in patients with rectal prolapse. Further study about combination treatment with biofeedback therapy in these subgroups may be necessary.

Successful Outcome of Refractory Chronic Constipation by Surgical Treatment: A Series of 34 Patients

Background/AimsChronic constipation is commonly managed medically, and surgical options have been advocated in patients with refractory symptoms. We aimed to study the role of surgical procedures in patients with constipation, refractory to medical therapy.MethodsData on 34 surgically managed patients with refractory chronic constipation during a 6-year period (March 2003 to May 2009) were retrospectively analyzed.ResultsAll the 34 patients (24 males and 10 females, median age of 45 years [range, 18-77 years]) had symptoms for a long period (median 96 months [range, 12-360 months]) without response to medical treatment including biofeedback. Preopertive investigations included barium enema, colonoscopy, colonic transit study, defecography and anorectal manometry as indicated. Eight patients (23.5%) had slow transit constipation, 4 (11.8%) had Hirschsprung's disease and 22 (64.7%) had rectal prolapse. Total colectomy and ileo-rectal anastomosis, anterior resection, Delorme's procedure, resection rectopexy and Duhamel's operation were the surgical procedures performed. Though 7 (20.6%) patients had post operative complications, there was no mortality. One patient whose symptoms recurred following anterior resection was successfully treated by total colectomy and ileo-rectal anastomosis. Median spontaneous bowel movements increased following surgical treatment compared to that while on medical treatment (1 per week [range, 0 to 3 per week] vs. 14 per week [range, 7-28 per week], P < 0.00001). Patients remained well during 3-60 months follow-up (n = 27).ConclusionsSpontaneous bowel movements significantly increased following surgical operation for refractory chronic constipation, nature of which is dependent on underlying etiology and the expertise available. Careful preoperative work-up and selection of patients are critical for obtaining good functional results.

Delorme's Procedure: An Effective Treatment for a Full-Thickness Rectal Prolapse in Young Patients

PurposeDelorme's procedure is infrequently applied in young adults because of its assumed higher recurrence rate. The aim of this prospective study was to assess the efficacy of the Delorme's technique in younger adults.MethodsFifty-two consecutive patients were entered in our study. We followed patients for at least 30 months. Their complaints and clinical exam results were noted.ResultsOur study included 52 patients (mean age, 38.44 years; standard deviation, 13.7 years). Of the included patients, 41 (78.8%) were younger than 50 years of age, and 11 (21.1%) were older than 50 years of age. No postoperative mortalities or major complications were noted. Minor complications were seen in 5 patients (9.6%) after surgery. The mean hospital stay was 2.5 days. In the younger group (age ≤50 years), fecal incontinence was improved in 92.3% (12 out of 13 with previous incontinence) of the patients, and recurrence was seen in 9.75% (4 patients). In the older group (age >50 years), fecal incontinence was improved in 20% (1 out of 5 with previous incontinence) of the patients, and recurrence was seen in 18.2% (2 patients). In 50% of the patients with a previous recurrence (3 out of 6 patients) following Delorme's procedure as a secondary procedure, recurrence was observed.ConclusionDelorme's procedure, especially in younger patients, is a relatively safe and effective treatment and should not be restricted to older frail patients. This procedure may not be suitable for recurrent cases.

Role of the Delorme Procedure for Rectal Prolapse in Young Patients

See Article on Page 60-65 It is known that patients with a short, full-thickness rectal prolapse can be treated with a mucosal sleeve resection; however, for a longer prolapse, a mucosal sleeve resection is associated with a higher recurrence rate compared with abdominal approaches. Thus, the Delorme procedure has been advocated for those who are considered high for an abdominal procedure because of comorbidities or to avoid the risk of nerve damage [1]. However, the recurrence rates are significantly different between younger patients with good pelvic floor musculature and elderly patients with a weak pelvic floor, a gaping anus, and a sliding hernia of the cul-de-sac [2, 3]. Constipation and fecal Incontinence improve following a Delorme operation, but urgency and tenesmus do occur. Improved anal sphincter and rectal sensation is associated with a reduced incidence of defecatory problems after a Delorme's procedure [4]. The Delorme procedure has a role in the treatment of rectal prolapse in young patients.

Delorme’s Procedure for Full-Thickness Rectal Prolapse; Does it Alter Anorectal Function

Clinical and anorectal manometric results of Delorme's procedure for full-thickness rectal prolapse were assessed retrospectively. Thirty-seven patients with full-thickness rectal prolapse who were operated on with Delorme's procedure were included in the study. They were 11 males and 26 females with mean age of 54 ± 4.4years (range 15-70years) and mean follow-up period of 27 ± 4.6months (15-48months). The mean operative time was 65 ± 4.5min (60-90min); there was no mortality and blood loss was minimal. Mean hospital stay was 3.5days (2-6days). Outcomes of the procedure were satisfactory in 29 patients (78.4%). Dissatisfaction came from recurrence and persistence of fecal incontinence. Prolapse recurrence had been observed in six patients; three of them were treated by the same technique and showed no recurrence, and the others were treated by either mucosal resection (1) or abdominal resection rectopexy (2). Constipated patients showed improved symptoms in 7 of 10 cases. Of 11 patients who were incontinent preoperatively, seven patients became fully continent. Postoperatively, anorectal manometric studies (MRP, MSP, MTV, and UDV) showed significant improvement in all patients with intact RAIR. Delorme's operation, coupled with avoidance of abdominal procedures, is the treatment of choice of rectal prolapse in elderly frail patients and in patients with defecatory disorders.

Delorme's Procedure for Complete Rectal Prolapse: Does It Still Have It's Own Role?

PurposeAlthough there are more than a hundred techniques, including the transabdominal and the perineal approaches, for the repair of the rectal prolapsed, none of them is perfect. The best repair should be chosen not only to correct the prolapse but also to restore defecatory function and to improve fecal incontinence throughout the patient's lifetime. The aim of this retrospective review is to evaluate clinical outcomes of the Delorme's procedure for the management of the complete rectal prolapse.MethodsA total of 19 patients (13 females and 6 males) with complete rectal prolapses were treated by using the Delorme's procedure in St. Vincent's Hospital, The Catholic University of Korea, from February 1997 to February 2007. Postoperative anal incontinence was evaluated using the Cleveland Clinic Incontinence Score.ResultsAll 19 patients had incontinence to liquid stool, solid stool, and/or flatus preoperatively. Three (15.8%) patients reported recurrence of the rectal prolapse (at 6, 18, 29 months, respectively, after the operation). Information on postoperative incontinence was available for 16 of the 19 patients. Twelve of the 16 patients (75%) reported improved continence (5 [31.3%] were improved and 7 [43.7%] completely recovered from incontinence) while 4 patients had unchanged incontinence symptoms. One (6.3%) patient who did not have constipation preoperatively developed constipation after the operation.ConclusionThe Delorme's procedure is associated with a marked improvement in anal continence, relatively low recurrence rates, and low incidence of postoperative constipation. This allows us to conclude that this procedure still has its own role in selected patients.

VI．直腸脱に対するDelorme法

VI．直腸脱に対するDelorme法

Conversion in transanal stapling techniques for haemorrhoids and anorectal prolapse

It was the aim of this single-surgeon series to assess the role of conversion in transanal stapling to techniques and to identify potential factors predictive of conversion. The details of all consecutive patients who were planned for a stapled approach were prospectively recorded in a PC database. Stapling techniques (PPH03, PPH01 and ContourTranstar) were indicated for haemorrhoidal disease and internal rectal prolapse. 'Conversion' from a stapled approach was defined as an unplanned change of the surgical method to a nonstapled, traditional technique, related to indication, anatomy and technical factors. The primary outcomes were whether the procedure was performed using a stapling device only, or whether the procedure was converted. Logistic regression analysis was performed to evaluate multiple variables as potential risk factors for conversion. In a 2-year period (May 2006-May 2008), 258 patients met the inclusion criteria and underwent transanal surgery scheduled as a stapled approach. In these 258 patients, 246 procedures were completed as a stapled procedure [that stapled haemorrhoidopexy, n = 148; stapled mucosectomy, n = 52; stapled transanal rectal resection (STARR) with PPH01, n = 38; and STARR with ContourTranstar, n = 8], giving a completion rate of 95.4%. However, 12 procedures were converted to conventional surgery (including traditional haemorrhoidectomy and the Delorme procedure), giving a conversion rate of 4.6%. The reasons for conversion were related to anatomy and to clinical findings (nonreducible haemorrhoidal prolapse), to new clinical findings not detected preoperatively (proctitis, anal fistula) and to a technical inability to insert the circular anal dilatator because of a deep anal canal. Neither univariate nor multivariate analysis identified any factor to be specifically associated with the risk of conversion. In the era of transanal stapling procedures for haemorrhoids and anorectal prolapse, the majority of procedures can be performed using stapled techniques if strict criteria of indication and patient selection are respected. However, the current study identified a 4.6% conversion rate to traditional treatment, which has an impact on informed consent and requires the surgeon to be familiar with conventional anorectal procedures.

Complete Rectal Prolapse in Adults: Clinical and Functional Results of Delorme Procedure Combined with Postanal Repair

This study has been performed at the Department of General Surgery, Zagazig University Hospital and King Saud Hospital, Oniza, KSAduring the period from November 1998 to September 2008.Twentyadult patients (6 males and 14 females with a mean age of 55years) with complete rectal prolapse were eligible for the study, Where Delorme's procedure and postanal repairwere combined. All patients presented with complete rectal prolapse at least 5cm in length. The associated disorders included constipation (4 patients, 20%), variable degrees of incontinence (15 patients, 75%). Only one patient had no associated functional problems. The median follow up period was 65months. There was no mortality and immediate postoperative complications developed in 4 patients (20%). Recurrence of the prolapse occurred in two patient. Eleven patients (73.3%) (11/17) with faecal incontinence showed postoperative improvement and 4 patients failed to improve. The 4 patients presented with constipation were all improved postoperatively. We conclude that the combination of Delorme's procedure and postanal repair in the treatment of complete rectal prolapse in adults is a safe procedure that corrects the anatomical defects and improves the functional outcome. We recommend use of this method in the treatment of complete rectal prolapse especially in the elderly who are complaining of faecal incontinence.

Transvaginal sacrospinous rectopexy: initial clinical experience

There is a wide range of surgical procedures available to treat rectal prolapse that differ in approach as well as in principle. The current perineal approaches available involve mucosal or full thickness resection. There are currently no accepted procedures combining rectal fixation without resection using the perineal approach. We present our initial report of transvaginal sacrospinous rectopexy for the treatment of rectal prolapse. A longitudinal incision was made in the posterior wall of the vagina. The rectum and sacrospinous ligament were identified. Two sutures were placed in the sacrospinous ligament and brought through a piece of Surgisis mesh previously anchored to the anterior surface of the rectum. This was performed bilaterally. These sutures were tied to complete the rectal suspension, and the posterior wall of the vagina was closed. Transvaginal sacrospinous rectopexy was performed in all seven cases. In the first two cases, a Delorme procedure was performed concurrently. Two patients had rubber band ligation for symptomatic internal hemorrhoids, one patient had a sphincter plication, and one patient had an anal encirclement procedure with Surgisis. Six of the seven patients had concomitant urologic procedures. The average operative time was 163 min, and the average blood loss was 107 mL. None of the cases required conversion to an open procedure. There was one full thickness recurrence at 18 weeks. Transvaginal sacrospinous rectopexy is a safe, minimally invasive, technically feasible technique for the treatment of rectal prolapse.

The Delorme repair for full-thickness rectal prolapse: a retrospective review

Background The purpose of this study was to assess our colorectal surgical training program experience with the Delorme procedure for complete rectal prolapse. Methods Consecutive patients were identified from a surgical database and evaluated by chart review. Results Seventy-six patients with a mean follow-up period of 3.6 years were included. Outcomes included a recurrence rate of 14.5%, an overall complication rate of 25%, and a surgical site-specific complication rate of 8%. For patients younger than 50 years old (mean age, 36 y; range, 19–49 y), the recurrence rate was 8% with a mean follow-up period of 4.1 years. Their total complication rate was 15%, with no surgery site-specific complications. Conclusions Our results are consistent with previously published experiences in that most preoperative evacuatory symptoms resolve with repair of the prolapse, and serious complications are uncommon. The observation that recurrence and complication rates may be lower in younger medically fit patients suggests the Delorme repair need not be restricted specifically to older, medically unfit patients.

Total rectal lumen obliteration after stapled haemorrhoidopexy: a cautionary tale

We describe obliteration of the rectal lumen during stapled haemorrhoidopexy in a patient with marked mucosal prolapse. The complication was recognised immediately and continuity was restored by performing a limited Delorme's procedure. The possible cause of this complication is explored and serves as a reminder that meticulous technique is required when performing stapled haemorrhoidopexy to prevent potentially disastrous complications.

Day case laparoscopic rectopexy is feasible, safe, and cost effective for selected patients

With the ever-present financial and bed pressures in the UK health care system, there is a drive toward increasing day surgery provision. Laparoscopic minimally invasive surgery lends itself well to the day case setting. This study aimed to show that day case laparoscopic rectopexy (DCLR) is safe, produces a good clinical outcome, and is cost effective for selected well-motivated patients. Since 2001, 28 patients have undergone procedures for rectal prolapse at the authors' institution. Of 12 laparoscopic rectopexy patients, 5 were selected for DCLR on the basis of home circumstances, general fitness, and patient wishes. Patient satisfaction with DCLR was assessed by telephone questionnaire. A retrospective analysis of case notes was performed to compare complications, analgesia requirements, and length of hospital stay. In-hospital costs for all rectal prolapse procedures were calculated. The DCLR group consisted of generally younger and fitter patients. One patient in the DCLR group had persistent abdominal pain and diarrhea requiring an emergency visit. Four of the five patients in the DCLR group were available for telephone interview. Three had stopped analgesia by the third day, reporting their experience as excellent or good. They had no hesitation recommending the procedure for day case usage. Whereas Delorme's procedure and inpatient laparoscopic rectopexy cost much the same, there is a clear cost benefit with DCLR for selected patients of approximately pound1,000 ($1,962) per patient. Day case laparoscopic rectopexy has never been reported previously. It is safe, feasible, and acceptable for selected well-motivated patients. Compared with Delorme's procedure and inpatient laparoscopic rectopexy, savings of pound1,000 per patient can be achieved because of an average 3-day decrease in bed occupancy.

Appearance of the Rectum on Barium Enema Examination After the Delorme Procedure

Appearance of the Rectum on Barium Enema Examination After the Delorme Procedure

Transanal Delorme procedure for treatment of rectocele associated with rectal intussusception

Transanal Delorme procedure for treatment of rectocele associated with rectal intussusception

Complete rectal prolapse clinical and functional outcome with Delorme's procedure: Resultados clínicos y funcionales con la operación de Delorme

Many surgical techniques -both through the perineal and abdominal routes- have been described for the treatment of rectal prolapse. The aim of this work is to evaluate the clinical and functional outcome with Delorme's perineal procedure.Twenty-one patients with complete rectal prolapse were studied from July 2000 to October 2005. Age, gender, anesthetic risk, and accompanying symptoms were all assessed. Diagnostic tests performed included: colonoscopy, anorectal manometry before and after surgery, and 360 masculine endoanal ultrasonography. Delorme's procedures were carried out by only one surgical team.No mortality occurred, and morbidity was minimal. Prolapse relapse rate was 9.52% with a mean follow-up of 34 months. Anal continence improved in 87.5% of patients, and no surgery-associated constipation ensued. Mean hospital stay was 2 (range 1-4) days. During the postoperative period no pain developed in 17 patients, and 4 patients had mild pain. Satisfaction with surgery was high in 16 cases (76.19%), moderate in 3 (14.28%), and low in 2 (9.52%).Delorme's procedure for the management of complete rectal prolapse is associated with low morbidity, improves anal continence, gives rise to no postsurgical constipation, and has an acceptable relapse rate. Patient satisfaction with this procedure is high because of its high comfortability (intradural anesthesia, short hospital stay, and little postoperative pain) and optimal results.

Physiological changes after Delorme's procedure for full-thickness rectal prolapse.

Anal sphincter pressures, rectal compliance and sensation in 19 women of mean age 77 (range 57-94) years were studied before and after Delorme's procedure for full-thickness rectal prolapse. No patient had significant problems with defaecation after operation. There were no significant changes in anal sphincter pressures but the volume of first rectal sensation decreased from a median of 140 ml before surgery to 65 ml after the procedure (P = 0.01) and the maximum tolerated rectal volume declined from a median of 249 ml to 120 ml (P = 0.001). Rectal compliance was reduced from a median of 142.9 ml/kPa to 12.2 ml/kPa (P = 0.002). Improved rectal sensation and lowered compliance are associated with a reduced incidence of defaecatory problems after Delorme's procedure.