C E du Boulay, J Fairbrother, P G Isaacson
Mucosal prolapse syndrome--a unifying concept for solitary ulcer syndrome and related disorders.
J Clin Pathol. 1983 Nov;36(11):1264-8.
Abstract/Text
Nineteen cases of classical solitary ulcer of the rectum syndrome (SURS) and sixteen examples of rectal mucosal prolapse are described. Similarities in the histological and histochemical features of the two groups lead us to suggest that the term "mucosal prolapse syndrome" be used to describe this group of disorders in which mucosal prolapse--overt or occult is the common underlying pathogenetic mechanism.
W B GABRIEL
Thiersch's operation for anal incontinence.
Proc R Soc Med. 1948 Jul;41(7):467.
Abstract/Text
In:Diseases of the Rectum, Anus and Colon, Including the Ileocolic Angle, Appendix, Colon, Sigmoid Flexure, Rectum, Anus, Buttocks, and Sacrococcygeal Region.Philadelphia: Vol IIW.B.Saunders, Co，1923; 22–57. chapter XXXVII．.
Tetsuo Yamana, Junichi Iwadare
Mucosal plication (Gant-Miwa procedure) with anal encircling for rectal prolapse--a review of the Japanese experience.
Dis Colon Rectum. 2003 Oct;46(10 Suppl):S94-9. doi: 10.1097/01.DCR.0000083390.03059.4C.
Abstract/Text
Although mucosal plication for rectal prolapse, known as the Gant-Miwa procedure, is described in some English textbooks, it has been infrequently performed in the West. However, this procedure has been used and developed in conjunction with anal encircling in Japan since the 1960s and is still considered to play a major role in the treatment of rectal prolapse. Certain technical details have been found necessary to ensure the success of the procedure, especially in the technique of anal encircling. For example, the use of Teflon tape and routing relatively deeply and outside the external anal sphincter are necessary. Clinical results show a recurrence rate of 0 to 31 percent with no mortality and almost never any serious complications such as significant bleeding or severe sepsis, which are occasionally encountered in other perineal procedures. Most patients report improved continence after this procedure, and worsening of evacuation is rarely encountered based on our experience. Some physiologic studies have shown improved resting pressure and rectal sensation, which can have a positive influence on the defecatory function. We believe that the Gant-Miwa procedure with anal encircling should be considered as a treatment of choice among perineal procedures for rectal prolapse.
Delorme.Sur le traitement des prolapsus du rectum totaux, par l’excision de la muqueuse rectale ou recto-colique. Bull Mém Soc Chir Paris, 1900；26 :499–518.
W A ALTEMEIER, J GIUSEFFI, P HOXWORTH
Treatment of extensive prolapse of the rectum in aged or debilitated patients.
AMA Arch Surg. 1952 Jul;65(1):72-80.
Abstract/Text
W A Altemeier, W R Culbertson, C Schowengerdt, J Hunt
Nineteen years' experience with the one-stage perineal repair of rectal prolapse.
Ann Surg. 1971 Jun;173(6):993-1006.
Abstract/Text
Longo A: Treatment of hemorrhoidal disease by reduction of mucosa and hemorrhoidal prolapse with circular suturing device: a new procedure. Rome: Proc 6th World Congr Endoscopic Surgery, 1998;777–790.
Shigeoki Hayashi, Hideki Masuda, Ichiro Hayashi, Hironobu Sato, Tadatoshi Takayama
Simple technique for repair of complete rectal prolapse using a circular stapler with Thiersch procedure.
Eur J Surg. 2002;168(2):124-7. doi: 10.1080/11024150252884368.
Abstract/Text
Yoshikazu Hachiro, Masao Kunimoto, Tatsuya Abe, Masahiro Kitada, Yoshiaki Ebisawa
Aluminum potassium sulfate and tannic acid injection in the treatment of total rectal prolapse: early outcomes.
Dis Colon Rectum. 2007 Nov;50(11):1996-2000. doi: 10.1007/s10350-007-9060-z. Epub 2007 Sep 27.
Abstract/Text
PURPOSE: No surgical method for repair of total rectal prolapse has been established as optimal. We describe a new technique that uses ALTA (aluminum potassium sulfate and tannic acid) injection as a simple perianal procedure for total rectal prolapse.
METHODS: Fourteen patients with total rectal prolapse were treated with sclerosing therapy by using ALTA injection. Via a perianal approach, 0.5 to 1 ml of ALTA solution was injected along a linear track into the submucosa at 30 to 80 different sites, totaling 20 to 60 ml.
RESULTS: All 14 patients treated with injection sclerotherapy were cured, with no intraoperative or postoperative complications. One patient required a repeat injection after two months to be cured. No exacerbation of constipation has resulted, and no stenosis has been evident on rectal examination. In seven of ten patients presenting with fecal incontinence, this complaint resolved after therapy.
CONCLUSIONS: ALTA sclerotherapy yielded satisfactory results in total rectal prolapse, causing no alteration in neurophysiology of bowel function. Injection sclerotherapy should be recommended as the first procedure for treatment of total rectal prolapse.
Joshua R Karas, Selman Uranues, Donato F Altomare, Selman Sokmen, Zoran Krivokapic, Jiri Hoch, Ivan Bartha, Roberto Bergamaschi, Rectal Prolapse Recurrence Study Group
No rectopexy versus rectopexy following rectal mobilization for full-thickness rectal prolapse: a randomized controlled trial.
Dis Colon Rectum. 2011 Jan;54(1):29-34. doi: 10.1007/DCR.0b013e3181fb3de3.
Abstract/Text
BACKGROUND: No randomized controlled trial has compared no rectopexy with rectopexy for external full-thickness rectal prolapse.
OBJECTIVE: This study was performed to test the hypothesis that recurrence rates following no rectopexy are not inferior to those following rectopexy for full-thickness rectal prolapse.
DESIGN: This was a multicenter randomized controlled trial. Eligible patients were randomly assigned to no rectopexy or rectopexy. The end point was recurrence rates defined as the presence of external full-thickness rectal prolapse after surgery. A prerandomized controlled trial meta-analysis suggested a sample size of 251 patients based on a 15% expected difference in the 5-year cumulative recurrence rate. Recurrence-free curves were generated and compared using the Kaplan-Meier method and log-rank test, respectively. Data were presented as median (range).
SETTING: This study was conducted in 41 tertiary centers in 21 countries.
PATIENTS: Patients with prior surgery for rectal prolapse or pelvic floor descent were not included.
INTERVENTIONS: The no-rectopexy arm was defined as abdominal surgery with rectal mobilization only. The rectopexy arm was defined as abdominal surgery with mobilization and rectopexy. Sigmoid resection was not randomized and was added in the presence of constipation.
MAIN OUTCOME MEASURES: Two hundred fifty-two patients with external full-thickness rectal prolapse were randomly assigned to undergo no rectopexy or rectopexy in 41 centers. All patients but one underwent the allocated intervention. One hundred sixteen no-rectopexy patients were comparable to 136 rectopexy patients for age (P = .21), body mass index (P = .61), ASA grade (P = .29), and previous abdominal surgery (P = .935), but not for sex (P = .013) and external full-thickness rectal prolapse length (8 (1-25) cm vs 5 (1-20) cm, P = .026). Sigmoid resection was performed more frequently in the no-rectopexy arm (P < .001). There was no significant difference in complication rates (11% vs 17.9%; P = .139). The mortality rate was 0.8%. The loss of patients to 5-year follow-up was 10.3%. Actuarial analysis demonstrated a significant difference in 5-year recurrence rates between study arms (8.6% vs 1.5%) (log-rank, P = .003).
LIMITATIONS: Limitations were the high proportion of male patients, randomization timing, the lack of standardization for rectopexy technique, and the 10% loss to follow-up.
CONCLUSIONS: Recurrence rates following no rectopexy are inferior to those following rectopexy for external full-thickness rectal prolapse.
G Salkeld, M Bagia, M Solomon
Economic impact of laparoscopic versus open abdominal rectopexy.
Br J Surg. 2004 Sep;91(9):1188-91. doi: 10.1002/bjs.4643.
Abstract/Text
BACKGROUND: The introduction of new laparoscopic techniques has important cost implications. The aim of this study was to compare the cost effectiveness of laparoscopic rectopexy with that of open abdominal rectopexy for full-thickness rectal prolapse.
METHODS: A cost effectiveness study was conducted alongside a randomized trial of laparoscopic versus open abdominal rectopexy.
RESULTS: The efficacy trial demonstrated significant subjective and objective differences in favour of the laparoscopic technique. The mean operating time was 51 min longer for laparoscopic rectopexy than for the open procedure. Laparoscopic disposables incurred a mean cost of pound 291 per patient. The mean duration of hospital stay was significantly shorter for the laparoscopic group (P = 0.001). Laparoscopic rectopexy was associated with an overall mean cost saving of pound 357 (95 per cent confidence interval pound 164 to pound 592; P = 0.042) per patient.
CONCLUSION: Laparoscopic rectopexy is associated with superior clinical outcomes and is cheaper than the open approach.
Copyright 2004 British Journal of Surgery Society Ltd.
F Cadeddu, P Sileri, M Grande, E De Luca, L Franceschilli, G Milito
Focus on abdominal rectopexy for full-thickness rectal prolapse: meta-analysis of literature.
Tech Coloproctol. 2012 Feb;16(1):37-53. doi: 10.1007/s10151-011-0798-x. Epub 2011 Dec 15.
Abstract/Text
BACKGROUND: Laparoscopic rectopexy to treat full-thickness rectal prolapse has proven short-term benefits, but there are few long-term follow-up and functional outcome data available. Using meta-analysis techniques, this study was designed to evaluate long-term results of open and laparoscopic abdominal procedures to treat full-thickness rectal prolapse in adults.
METHODS: A literature review was performed using the National Library of Medicine's PubMed database. All articles on abdominal rectopexy patients with a follow-up longer than 16 months were considered. The primary end point was recurrence of rectal prolapse, and the secondary end points were improvement in incontinence and constipation. A random effect model was used to aggregate the studies reporting these outcomes, and heterogeneity was assessed.
RESULTS: Eight comparative studies, consisting of a total of 467 patients (275 open and 192 laparoscopic), were included. Analysis of the data suggested that there is no significant difference in recurrence, incontinence and constipation improvement between laparoscopic abdominal rectopexy and open abdominal rectopexy. Considering non-comparative trials, the event rate for recurrence was similar in open and laparoscopic suture rectopexy studies and in open and laparoscopic mesh rectopexy trials. Improvement in constipation after the intervention was not statistically significant except for open mesh repair; postoperative improvement in incontinence was statistically significant after laparoscopic procedures and open mesh rectopexy.
CONCLUSIONS: Laparoscopic abdominal rectopexy is a safe and feasible procedure, which may compare equally with the open technique with regard to recurrence, incontinence and constipation. However, large-scale randomized trials, with comparative, strong methodology, are still needed to identify outcome measures accurately.
H A Formijne Jonkers, N Poierrié, W A Draaisma, I A M J Broeders, E C J Consten
Laparoscopic ventral rectopexy for rectal prolapse and symptomatic rectocele: an analysis of 245 consecutive patients.
Colorectal Dis. 2013 Jun;15(6):695-9. doi: 10.1111/codi.12113.
Abstract/Text
AIM: This retrospective study aimed to determine functional results of laparoscopic ventral rectopexy (LVR) for rectal prolapse (RP) and symptomatic rectoceles in a large cohort of patients.
METHOD: All patients treated between 2004 and 2011 were identified. Relevant patient characteristics were gathered. A questionnaire concerning disease-related symptoms as well as the Cleveland Clinic Incontinence Score (CCIS) and Cleveland Clinic Constipation Score (CCCS) was sent to all patients.
RESULTS: A total of 245 patients underwent operation. Twelve patients (5%) died during follow-up and were excluded. The remaining patients (224 women, nine men) were sent a questionnaire. Indications for LVR were external RP (n = 36), internal RP or symptomatic rectocele (n = 157) or a combination of symptomatic rectocele and enterocele (n = 40). Mean age and follow-up were 62 years (range 22-89) and 30 months (range 5-83), respectively. Response rate was 64% (150 patients). The complication rate was 4.6% (11 complications). A significant reduction in symptoms of constipation or obstructed defaecation syndrome was reported (53% of patients before vs 19% after surgery, P < 0.001). Mean CCCS during follow-up was 8.1 points (range 0-23, SD ± 4.3). Incontinence was reported in 138 (59%) of the patients before surgery and in 32 (14%) of the patients after surgery, indicating a significant reduction (P < 0.001). Mean CCIS was 6.7 (range 0-19, SD ± 5.2) after surgery.
CONCLUSION: A significant reduction of incontinence and constipation or obstructed defaecation syndrome after LVR was observed in this large retrospective study. LVR therefore appears a suitable treatment for RP and rectocele with and without associated enterocele.
Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.
Charles Evans, Andrew R L Stevenson, Pierpaolo Sileri, Mark A Mercer-Jones, Anthony R Dixon, Chris Cunningham, Oliver M Jones, Ian Lindsey
A Multicenter Collaboration to Assess the Safety of Laparoscopic Ventral Rectopexy.
Dis Colon Rectum. 2015 Aug;58(8):799-807. doi: 10.1097/DCR.0000000000000402.
Abstract/Text
BACKGROUND: Concerns have been raised regarding the potential risk of mesh complications after laparoscopic ventral rectopexy.
OBJECTIVE: This study aimed to determine the risk of mesh and nonmesh morbidity after laparoscopic ventral rectopexy and to compare the safety of synthetic meshes with biological grafts.
DESIGN: This was a retrospective review.
SETTINGS: The study used data collated from prospective pelvic floor databases in 5 centers (3 in the United Kingdom, 1 in Australia, and 1 in Italy).
PATIENTS: All of the patients undergoing laparoscopic ventral rectopexy over a 14-year period (1999-2013) at these centers were included in the study.
MAIN OUTCOME MEASURES: The primary outcome was mesh morbidity, classified as vaginal erosion, rectal erosion, rectovaginal fistula, or perineal erosion. Secondary outcomes were nonmesh morbidity.
RESULTS: A total of 2203 patients underwent surgery; 1764 (80.1%) used synthetic mesh and 439 (19.9%) used biological grafts. There were 2 postoperative deaths (0.1%). Forty-five patients (2.0%) had mesh erosion, including 20 vaginal, 17 rectal, 7 rectovaginal fistula, and 1 perineal. Twenty-three patients (51.1%) required treatment for minor erosion morbidity (local excision of stitch/exposed mesh), and 18 patients (40.0%) were treated for major erosion morbidity (12 laparoscopic mesh removal, 3 mesh removal plus colostomy, and 3 anterior resection). Erosion occurred in 2.4% of synthetic meshes and 0.7% of biological meshes. The median time to erosion was 23 months. Nonmesh complications occurred in 11.1% of patients.
LIMITATIONS: This was a retrospective study including patients with minimal follow-up. The study was unable to determine whether patients will develop future erosions, currently have asymptomatic erosions, or have been treated in other institutions for erosions.
CONCLUSIONS: Laparoscopic ventral rectopexy is a safe operation. Mesh erosion rates are 2% and occasionally require resectional surgery that might be reduced by the use of biological graft. An international ventral mesh registry is recommended to monitor mesh problems and to assess whether type of mesh has any impact on functional outcomes or the need for revisional surgery for nonerosion problems.
Esther C J Consten, Jan J van Iersel, Paul M Verheijen, Ivo A M J Broeders, Albert M Wolthuis, Andre D'Hoore
Long-term Outcome After Laparoscopic Ventral Mesh Rectopexy: An Observational Study of 919 Consecutive Patients.
Ann Surg. 2015 Nov;262(5):742-7; discussion 747-8. doi: 10.1097/SLA.0000000000001401.
Abstract/Text
OBJECTIVE: This multicenter study aims to assess long-term functional outcome, early and late (mesh-related) complications, and recurrences after laparoscopic ventral mesh rectopexy (LVR) for rectal prolapse syndromes in a large cohort of consecutive patients.
BACKGROUND: Long-term outcome data for prolapse repair are rare. A high incidence of mesh-related problems has been noted after transvaginal approaches using nonresorbable meshes.
METHODS: All patients treated with LVR at the Meander Medical Centre, Amersfoort, the Netherlands and the University Hospital Leuven, Belgium between January 1999 and March 2013 were enrolled in this study. All data were retrieved from a prospectively maintained database. Kaplan-Meier estimates were calculated for recurrences and mesh-related problems.
RESULTS: 919 consecutive patients (869 women; 50 men) underwent LVR. A 10-year recurrence rate of 8.2% (95% confidence interval, 3.7-12.7) for external rectal prolapse repair was noted. Mesh-related complications were recorded in 18 patients (4.6%), of which mesh erosion to the vagina occurred in 7 patients (1.3%). In 5 of these patients, LVR was combined with a perineotomy. Both rates of fecal incontinence and obstructed defecation decreased significantly (P < 0.0001) after LVR compared to the preoperative incidence (11.1% vs 37.5% for incontinence and 15.6% vs 54.0% for constipation).
CONCLUSIONS: LVR is safe and effective for the treatment of different rectal prolapse syndromes. Long-term recurrence rates are in line with classic types of mesh rectopexy and occurrence of mesh-related complications is rare.
Fatma A Gultekin, Mark T C Wong, Juliette Podevin, Marie-Line Barussaud, Myriam Boutami, Paul A Lehur, Guillaume Meurette
Safety of laparoscopic ventral rectopexy in the elderly: results from a nationwide database.
Dis Colon Rectum. 2015 Mar;58(3):339-43. doi: 10.1097/DCR.0000000000000308.
Abstract/Text
BACKGROUND: Laparoscopic ventral rectopexy is an established procedure in the treatment of posterior pelvic organ prolapse. It is still unclear whether this procedure can be performed safely in the elderly.
OBJECTIVE: This study aimed to assess the effects of age on the outcome of laparoscopic ventral rectopexy performed for patients with pelvic organ prolapse.
DESIGN: This study was a retrospective cohort analysis with data from a national registry.
SETTINGS: The study was conducted in a tertiary care setting.
PATIENTS: Patients undergoing laparoscopic ventral rectopexy were identified from discharge summaries. Patients were stratified according to age, including patients <70 (group A) and ≥ 70 (group B) years old.
MAIN OUTCOME MEASURES: Variables analyzed included sex, age, diagnosis, associated pelvic organ prolapse, comorbidities, length of stay, complications (Clavien-Dindo scale), and mortality.
RESULTS: Among 4303 patients (98.2% women) who underwent a laparoscopic ventral rectopexy, 1263 (29.4%) were >70 years old (mean age, 76.2 ± 5.0 years). Main diagnoses were vaginal vault prolapse (53.0% [group A] vs 47.0% [group B]; p value not significant) and rectal prolapse (17.7 vs 26.8%; p value not significant). Comorbidity was significantly increased in group B (mean length of stay, 5.6 ± 3.6 vs 4.7 ± 1.8 days; p < 0.001) and minor complications (8.4% vs 5.0%; p < 0.001) were significantly increased in group B, whereas major complications were not different (group A, 0.7%; group B, 0.9%; p = 0.40) after univariate analysis. Multivariate analysis found no significant differences between groups. The subgroup analysis of patients >80 years old (n = 299) showed no differences. Each group had 1 postoperative mortality.
LIMITATIONS: Limitations of the study include its retrospective design, lack of prestudy power calculation, possible inaccuracy of an administrative database, and selection bias.
CONCLUSIONS: Laparoscopic ventral rectopexy appears to be safe in select elderly patients.
Akira Tsunoda
Surgical Treatment of Rectal Prolapse in the Laparoscopic Era; A Review of the Literature.
J Anus Rectum Colon. 2020;4(3):89-99. doi: 10.23922/jarc.2019-035. Epub 2020 Jul 30.
Abstract/Text
Rectal prolapse is associated with debilitating symptoms including the discomfort of prolapsing tissue, mucus discharge, hemorrhage, and defecation disorders of fecal incontinence, constipation, or both. The aim of treatment is to eliminate the prolapse, correct associated bowel function and prevent new onset of bowel dysfunction. Historically, abdominal procedures have been indicated for young fit patients, whereas perineal approaches have been preferred in older frail patients with significant comorbidity. Recently, the laparoscopic procedures with their advantages of less pain, early recovery, and lower morbidity have emerged as an effective tool for the treatment of rectal prolapse. This article aimed to review the current evidence base for laparoscopic procedures and perineal procedures, and to compare the results of various techniques. As a result, laparoscopic procedures showed a relatively low recurrence rate than the perineal procedures with comparable complication rates. Laparoscopic resection rectopexy and laparoscopic ventral mesh rectopexy had a small advantage in the improvement of constipation or the prevention of new-onset constipation compared with other laparoscopic procedures. However, the optimal surgical repair has not been clearly demonstrated because of the significant heterogeneity of available studies. An individualized approach is recommended for every patient, considering age, comorbidity, and the underlying anatomical and functional disorders.
Copyright © 2020 by The Japan Society of Coloproctology.
Samson Tou, Steven R Brown, Richard L Nelson
Surgery for complete (full-thickness) rectal prolapse in adults.
Cochrane Database Syst Rev. 2015 Nov 24;2015(11):CD001758. doi: 10.1002/14651858.CD001758.pub3. Epub 2015 Nov 24.
Abstract/Text
BACKGROUND: Complete (full-thickness) rectal prolapse is a lifestyle-altering disability that commonly affects older people. The range of surgical methods available to correct the underlying pelvic floor defects in full-thickness rectal prolapse reflects the lack of consensus regarding the best operation.
OBJECTIVES: To assess the effects of different surgical repairs for complete (full-thickness) rectal prolapse.
SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register up to 3 February 2015; it contains trials from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) as well as trials identified through handsearches of journals and conference proceedings. We also searched EMBASE and EMBASE Classic (1947 to February 2015) and PubMed (January 1950 to December 2014), and we specifically handsearched theBritish Journal of Surgery (January 1995 to June 2014), Diseases of the Colon and Rectum (January 1995 to June 2014) and Colorectal Diseases (January 2000 to June 2014), as well as the proceedings of the Association of Coloproctology meetings (January 2000 to December 2014). Finally, we handsearched reference lists of all relevant articles to identify additional trials.
SELECTION CRITERIA: All randomised controlled trials (RCTs) of surgery for managing full-thickness rectal prolapse in adults.
DATA COLLECTION AND ANALYSIS: Two reviewers independently selected studies from the literature searches, assessed the methodological quality of eligible trials and extracted data. The four primary outcome measures were the number of patients with recurrent rectal prolapse, number of patients with residual mucosal prolapse, number of patients with faecal incontinence and number of patients with constipation.
MAIN RESULTS: We included 15 RCTs involving 1007 participants in this third review update. One trial compared abdominal with perineal approaches to surgery, three trials compared fixation methods, three trials looked at the effects of lateral ligament division, one trial compared techniques of rectosigmoidectomy, two trials compared laparoscopic with open surgery, and two trials compared resection with no resection rectopexy. One new trial compared rectopexy versus rectal mobilisation only (no rectopexy), performed with either open or laparoscopic surgery. One new trial compared different techniques used in perineal surgery, and another included three comparisons: abdominal versus perineal surgery, resection versus no resection rectopexy in abdominal surgery and different techniques used in perineal surgery.The heterogeneity of the trial objectives, interventions and outcomes made analysis difficult. Many review objectives were covered by only one or two studies with small numbers of participants. Given these caveats, there is insufficient data to say which of the abdominal and perineal approaches are most effective. There were no detectable differences between the methods used for fixation during rectopexy. Division, rather than preservation, of the lateral ligaments was associated with less recurrent prolapse but more postoperative constipation. Laparoscopic rectopexy was associated with fewer postoperative complications and shorter hospital stay than open rectopexy. Bowel resection during rectopexy was associated with lower rates of constipation. Recurrence of full-thickness prolapse was greater for mobilisation of the rectum only compared with rectopexy. There were no differences in quality of life for patients who underwent the different kinds of prolapse surgery.
AUTHORS' CONCLUSIONS: The lack of high quality evidence on different techniques, together with the small sample size of included trials and their methodological weaknesses, severely limit the usefulness of this review for guiding practice. It is impossible to identify or refute clinically important differences between the alternative surgical operations. Longer follow-up with current studies and larger rigorous trials are needed to improve the evidence base and to define the optimum surgical treatment for full-thickness rectal prolapse.
Patrick B Murphy, Kerollos Wanis, Christopher M Schlachta, Nawar A Alkhamesi
Systematic review on recent advances in the surgical management of rectal prolapse.
Minerva Chir. 2017 Feb;72(1):71-80. doi: 10.23736/S0026-4733.16.07205-9. Epub 2016 Oct 6.
Abstract/Text
INTRODUCTION: Surgical management of external rectal prolapse (ERP) remains a challenge with the breadth of choices available and varies on the international, national, regional and locoregional level. Significant innovation has led to new techniques to manage ERP including changes to both abdominal and perineal approaches.
EVIDENCE ACQUISITION: A systematic, English-language search of major databases was conducted from 2006-2016. From 636 papers two reviewers identified 24 studies which compared two or more surgical techniques in adult patients with rectal prolapse and reported on complications, quality of life or recurrence. The Newcastle-Ottawa Scale (NOS) was used to score quality in non-randomized control trials (RCT) and the Cochrane Collaboration tool was use for RCTs.
EVIDENCE SYNTHESIS: Abdominal and perianal surgeries both result in the resolution of symptoms and an improvement of quality of life for most patients. Short-term outcomes generally favored laparoscopy. Rectopexy with or without resection confers balances a low risk of recurrence with a similar complication rate to perineal surgery. The quality of included studies was general poor and most was at significant risk of bias.
CONCLUSIONS: Most studies are of low quality and surgical management should be individualized to balance risk of the operation and the potential benefit to quality of life. Laparoscopy and modern anesthesia has made the abdominal approach more attractive even for elderly patients.
C B RIPSTEIN
Treatment of massive rectal prolapse.
Am J Surg. 1952 Jan;83(1):68-71.
Abstract/Text
C WELLS
New operation for rectal prolapse.
Proc R Soc Med. 1959 Aug;52:602-3.
Abstract/Text
I R Berman
Sutureless laparoscopic rectopexy for procidentia. Technique and implications.
Dis Colon Rectum. 1992 Jul;35(7):689-93.
Abstract/Text
Procedures for treating rectal prolapse may constitute some of the best applications for colorectal laparoscopic techniques. Although the condition is benign, rectal prolapse is often debilitating and frequently progressive in terms of functional limitations. Moreover, many patients are elderly, medically unfit, or both. A technique that afforded relief of prolapse and of incontinence by laparoscopic rectal sacropexy, performed without sutures, using a newly designed laparoscopic sacral tacker and laparoscopic staples, is described. Indications, contraindications, technical details, and surgical implications are discussed. Laparoscopic pelvic suspension procedures are presented as realistic and appropriate objectives for colon and rectal surgeons.
A D'Hoore, R Cadoni, F Penninckx
Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse.
Br J Surg. 2004 Nov;91(11):1500-5. doi: 10.1002/bjs.4779.
Abstract/Text
BACKGROUND: Postoperative constipation is a common problem with most mesh suspension techniques used to correct rectal prolapse. Autonomic denervation of the rectum subsequent to its complete mobilization has been suggested as a contributory factor. The aim of this study was to assess the long-term outcome of patients who underwent a novel, autonomic nerve-sparing, laparoscopic technique for rectal prolapse.
METHODS: Between 1995 and 1999, 42 patients had laparoscopic ventral rectopexy for total rectal prolapse. The long-term results after a median follow-up of 61 (range 29-98) months were analysed.
RESULTS: There were no major postoperative complications. Late recurrence occurred in two patients. In 28 of 31 patients with incontinence there was a significant improvement in continence. Symptoms of obstructed defaecation resolved in 16 of 19 patients. During follow-up, new onset of mild obstructed defaecation was noted in only two patients. Symptoms suggestive of slow-transit colonic obstipation were not induced.
CONCLUSION: Laparoscopic ventral rectopexy is an effective technique for the correction of rectal prolapse and appears to avoid severe postoperative constipation. The ventral position of the prosthesis may explain the beneficial effect on symptoms of obstructed defaecation.
Copyright (c) 2004 British Journal of Surgery Society Ltd
A D'Hoore, F Penninckx
Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients.
Surg Endosc. 2006 Dec;20(12):1919-23. doi: 10.1007/s00464-005-0485-y.
Abstract/Text
The authors propose a new laparoscopic technique for correction of rectal prolapse. The unique feature of this technique is that it avoids any posterolateral dissection of the rectum. The mesh is sutured to the anterior aspect of the rectum to inhibit intussusception. The technique was applied in 109 consecutive patients to correct total rectal prolapse. Conversion was needed for four patients. No postoperative mortality or major morbidity occurred. Minor morbidity was noted for 7% of the patients, and a recurrence rate of 3.66% was observed. Because this technique limited the dissection and the subsequent risk of autonomic nerve damage, a cure comparable with that resulting from classical mesh rectopexy can be anticipated.
Jean-Luc Faucheron, Bertrand Trilling, Edouard Girard, Pierre-Yves Sage, Sandrine Barbois, Fabian Reche
Anterior rectopexy for full-thickness rectal prolapse: Technical and functional results.
World J Gastroenterol. 2015 Apr 28;21(16):5049-55. doi: 10.3748/wjg.v21.i16.5049.
Abstract/Text
AIM: To assess effectiveness, complications, recurrence rate, and recent improvements of the anterior rectopexy procedure for treatment of total rectal prolapse.
METHODS: MEDLINE, PubMed, EMBASE, and other relevant database were searched to identify studies. Randomized controlled trials, non-randomized studies and original articles in English language, with more than 10 patients who underwent laparoscopic ventral rectopexy for full-thickness rectal prolapse, with a follow-up over 3 mo were considered for the review.
RESULTS: Twelve non-randomized case series studies with 574 patients were included in the review. No surgical mortality was described. Conversion was needed in 17 cases (2.9%), most often due to difficult adhesiolysis. Twenty eight patients (4.8%) presented with major complications. Seven (1.2%) mesh-related complications were reported. Most frequent complications were urinary tract infection and urinary retention. Mean recurrence rate was 4.7% with a median follow-up of 23 mo. Improvement of constipation ranged from 3%-72% of the patients and worsening or new onset occurred in 0%-20%. Incontinence improved in 31%-84% patients who presented fecal incontinence at various stages. Evaluation of functional score was disparate between studies.
CONCLUSION: Based on the low long-term recurrence rate and favorable outcome data in terms of low de novo constipation rate, improvement of anal incontinence, and low complications rate, laparoscopic anterior rectopexy seems to emerge as an efficient procedure for the treatment of patients with total rectal prolapse.
Seung-Hyun Lee, Paryush Lakhtaria, Jorge Canedo, Yoon-Suk Lee, Steven D Wexner
Outcome of laparoscopic rectopexy versus perineal rectosigmoidectomy for full-thickness rectal prolapse in elderly patients.
Surg Endosc. 2011 Aug;25(8):2699-702. doi: 10.1007/s00464-011-1632-2. Epub 2011 Apr 9.
Abstract/Text
BACKGROUND: The balance between abdominal and perineal approaches for rectal prolapse is always the higher morbidity but better outcome in the former setting. Therefore, perineal approaches have been preferred for the treatment of full-thickness rectal prolapse (FTRP) in elderly patients. However, laparoscopic rectopexy with or without resection also may be used for elderly patients and may confer the same benefits.
PURPOSE: The objective of this study was to evaluate safety and efficacy of laparoscopic rectopexy compared with perineal rectosigmoidectomy for FTRP in elderly patients.
METHODS: Between July 2000 and June 2009, eight consecutive patients (8 women; mean age, 71 (range, 65-77) years) with FTRP underwent laparoscopic rectopexy (LAP group). During the same period, 143 patients underwent perineal rectosigmoidectomy (PRS group). A total of 123 patients were selected who underwent perineal rectosigmoidectomy (117 women; mean age, 80.7 (range, 66-98) years).
RESULTS: Three patients (37.5%) in the LAP group and 29 patients (23.6%) in the PRS group had undergone previous operations for rectal prolapse. The mean follow-up periods were 6.9 months and 12.8 months, respectively. In the LAP group, operative time was longer (166.5 vs. 73.5 minutes; p > 0.05) and bleeding loss was more (101.7 vs. 31.6; p < 0.05), whereas the length of hospitalization was same between the two groups (5.4 vs. 5.3 days; p > 0.05). Postoperative complications included an incisional hernia in the LAP group (12.5%) and urinary retention (4.8%), anastomotic disruption (2.4%), urinary tract infection (1.6%), and atelectasis (1.6%) in the PRS group (13.8%). Recurrences were 1 (12.5%) in the LAP group and 14 (11.4%) in the PRS group.
CONCLUSIONS: Laparoscopic rectopexy is a safe and feasible procedure in elderly patients with FTRP but results in increased operative time.
Jian-Hua Ding, Jorge Canedo, Seung-Hyun Lee, Sudhir N Kalaskar, Lester Rosen, Steven D Wexner
Perineal rectosigmoidectomy for primary and recurrent rectal prolapse: are the results comparable the second time?
Dis Colon Rectum. 2012 Jun;55(6):666-70. doi: 10.1097/DCR.0b013e31825042c5.
Abstract/Text
BACKGROUND: The surgical approach to recurrent full-thickness rectal prolapse after perineal rectosigmoidectomy is complicated by recurrent prolapse. The majority of patients who undergo perineal rectosigmoidectomy are elderly with comorbidities. Therefore, redo perineal rectosigmoidectomy is usually selected to avoid postoperative complications.
OBJECTIVE: This study aimed to evaluate the safety and efficacy of redo perineal rectosigmoidectomy for recurrent full-thickness rectal prolapse.
DESIGN: This is a retrospective cohort study.
SETTING: This study was conducted at Cleveland Clinic Florida, from January 2000 to March 2009.
PATIENTS: One hundred thirty-six patients (129 women), mean age 78 (range, 31-98) years, were included in the study; 113 patients with full-thickness rectal prolapse underwent primary perineal rectosigmoidectomy, and 23 patients with recurrent full-thickness rectal prolapse underwent redo perineal rectosigmoidectomy.
INTERVENTIONS: All patients underwent perineal rectosigmoidectomy.
MAIN OUTCOME MEASURES: Perioperative outcomes, recurrence curves, and risk of recurrence were compared between the 2 groups. Age, anterior compartment prolapse, concurrent levatorplasty, and length of bowel resection were analyzed to identify factors potentially influencing recurrence.
RESULTS: Both groups had comparable demographics, BMI, and ASA scores. Operative time, blood loss, length of bowel resection, hospital stay, and follow-up (mean, 42.5 months) were similar in both groups. There was no significant difference in overall complication rates (redo perineal rectosigmoidectomy 17.4% vs. primary perineal rectosigmoidectomy 16.8%; p = 1.00). The recurrence rate for full-thickness rectal prolapse was significantly higher for redo perineal rectosigmoidectomy than primary perineal rectosigmoidectomy (39% vs. 18%; p = 0.007). None of the factors analyzed was associated with recurrence in either group.
LIMITATIONS: This study was limited by its retrospective methodology. In addition, functional outcomes were not evaluated, because many of the patients died during the follow-up period or were unavailable because of advanced age.
CONCLUSIONS: Redo perineal rectosigmoidectomy is as safe and feasible as primary perineal rectosigmoidectomy in elderly and fragile patients with recurrent full-thickness rectal prolapse. However, the re-recurrence rate for full-thickness rectal prolapse is substantially higher for redo perineal rectosigmoidectomy than primary perineal rectosigmoidectomy.
S W Chun, A J Pikarsky, S Y You, P Gervaz, J Efron, E Weiss, J J Nogueras, S D Wexner
Perineal rectosigmoidectomy for rectal prolapse: role of levatorplasty.
Tech Coloproctol. 2004 Mar;8(1):3-8; discussion 8-9. doi: 10.1007/s10151-004-0042-z.
Abstract/Text
BACKGROUND: The management of full thickness rectal prolapse remains controversial. Although abdominal approaches have a lower recurrence rate than do perineal operations, they are associated with a higher morbidity. The aim of this study was to compare the outcomes of perineal rectosigmoidectomy with and without levatorplasty.
METHODS: Between 1989 and 1999, a total of 109 consecutive patients (10 men) underwent 120 perineal procedures. These patients were retrospectively evaluated in two groups on the basis of the type of surgery received: perineal rectosigmoidectomy (PRS) or perineal rectosigmoidectomy with levatorplasty (PRSL). Subsequent functional outcome and physiological parameters were assessed.
RESULTS: The patients had a mean age of 75.7 years (range, 23.0-94.8 years) and they were followed for an overall mean (in both groups combined) of 28.0 months (range, 0.4-126.4 months) after surgery. Mean duration of surgery was 78.1 min (SD=25.9) and 97.6 min (SD=32.3) in PRS and PRSL, respectively ( p=0.002, unpaired t test). There was no significant difference between the two groups in terms of hospital stay, morbidity or mortality. Recurrence rates and mean time interval to recurrence were, respectively, 20.6% and 45.5 months in PRS compared to 7.7% and 13.3 months in PRSL ( p=0.049, chi-square test; p=0.001, unpaired t test). Both groups had significant improvements in postoperative incontinence score ( p<0.0001, Wilcoxon's matched-pairs signed-ranks test), however, there were no significant changes in anorectal manometric findings and pudendal nerve terminal motor latency assessment.
CONCLUSIONS: Perineal rectosigmoidectomy with levatorplasty is associated with a lower recurrence rate and a longer time to recurrence than perineal rectosigmoidectomy alone. Levatorplasty should be offered to patients when a perineal approach for rectal prolapse is selected.
