今日の臨床サポート

直腸脱・粘膜脱症候群

著者: 井上靖浩1) 遠山病院 外科

著者: 藤川裕之2) 三重大学 消化管・小児外科学

著者: 廣純一郎3) 三重大学 消化管・小児外科学

著者: 楠正人4) 三重大学 消化管・小児外科学

監修: 杉原健一 東京医科歯科大学大学院

著者校正/監修レビュー済:2020/05/14
参考ガイドライン:
  1. 日本大腸肛門病学会:肛門疾患(痔核・痔瘻・裂肛)・直腸脱診療ガイドライン2020年版. 南江堂, 2020年
患者向け説明資料

概要・推奨   

  1. 会陰式直腸・S状結腸切除術は、高齢者完全直腸脱患者における初回手術のみならず、再発直腸脱に対しても安全かつ有効である(推奨度3)。
  1. 高齢者完全直腸脱に対する腹腔鏡下手術は、会陰式直腸・S状結腸切除術に比較し、手術時間の延長はみられるが、安全で有用な手術選択になり得る(推奨度2)。
  1. 肛門挙筋形成術(levatoroplasty)は会陰式直腸・S状結腸切除術における再発予防に有用である(推奨度3)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
井上靖浩 : 特に申告事項無し[2021年]
藤川裕之 : 未申告[2021年]
廣純一郎 : 特に申告事項無し[2021年]
楠正人 : 未申告[2021年]
監修:杉原健一 : 講演料(大鵬薬品)[2021年]

改訂のポイント:
  1. 肛門疾患(痔核・痔瘻・裂肛)・直腸脱診療ガイドライン2020年版に基づき、手術の適応及び選択について改訂を行った。 

病態・疫学・診察

疾患情報(疫学・病態)  
完全直腸脱:
  1. 直腸の全層が脱出する病態を完全直腸脱と呼び、内痔核などを基点とし粘膜のみ脱出する不完全直腸脱とは病態が異なる。
  1. 完全直腸脱の病因論として、①直腸の重積説と、②ダグラス窩の滑脱ヘルニア説とがあり、ときには両者が併存する。
  1. 二次的な誘因として骨盤底筋群の弛緩、肛門挙筋の離解、括約筋機能障害、骨盤内臓器の下降、直腸・S状結腸過長症、不適切な排便習慣などが挙げられる。
 
直腸脱の病態

完全直腸脱の誘因

出典

img1:  著者提供
 
 
 
  1. 高齢女性に多く、便失禁との関連が50~70%にみられる。
  1. 小児の直腸脱は成人とは異なる病因が考えられている。
 
小児直腸脱病因

病因が成人と異なり、解剖学的見地から仙骨の直立化、S状結腸の固定不良、直腸粘膜の筋層に対する固定不良、Houston弁の消失などが、関与すると考えられている。

出典

img1:  著者提供
 
 
 
不完全直腸脱:
  1. 不完全直腸脱の代表疾患である粘膜脱症候群(mucosal prolapse syndrome、MPS)は1983年、du Boulayらにより提唱された概念である[1]
  1. MPSは肛門縁から7~10cm付近の直腸前壁に好発する非特異的潰瘍を主体とする病態であり、歴史的には孤立性潰瘍症候群(solitary ulcer syndrome)や深在嚢胞性大腸炎(localized colitis cystica profunda)などとしても知られてきた。
  1. MPSの成因として直腸粘膜の下垂・脱出が関与しているとされていることから、両者を総称した診断名がMPSとされる。
問診・診察のポイント  
  1. 排便時、安静時における症状の詳細を問診する。

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文献 

著者: C E du Boulay, J Fairbrother, P G Isaacson
雑誌名: 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.

PMID 6630576  J Clin Pathol. 1983 Nov;36(11):1264-8.
著者: W B GABRIEL
雑誌名: Proc R Soc Med. 1948 Jul;41(7):467.
Abstract/Text
PMID 18872171  Proc R Soc Med. 1948 Jul;41(7):467.
著者: Tetsuo Yamana, Junichi Iwadare
雑誌名: 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.

PMID 14530665  Dis Colon Rectum. 2003 Oct;46(10 Suppl):S94-9. doi: 10.・・・
著者: W A ALTEMEIER, J GIUSEFFI, P HOXWORTH
雑誌名: AMA Arch Surg. 1952 Jul;65(1):72-80.
Abstract/Text
PMID 14932600  AMA Arch Surg. 1952 Jul;65(1):72-80.
著者: W A Altemeier, W R Culbertson, C Schowengerdt, J Hunt
雑誌名: Ann Surg. 1971 Jun;173(6):993-1006.
Abstract/Text
PMID 5578808  Ann Surg. 1971 Jun;173(6):993-1006.
著者: Shigeoki Hayashi, Hideki Masuda, Ichiro Hayashi, Hironobu Sato, Tadatoshi Takayama
雑誌名: Eur J Surg. 2002;168(2):124-7. doi: 10.1080/11024150252884368.
Abstract/Text
PMID 12113270  Eur J Surg. 2002;168(2):124-7. doi: 10.1080/11024150252・・・
著者: Yoshikazu Hachiro, Masao Kunimoto, Tatsuya Abe, Masahiro Kitada, Yoshiaki Ebisawa
雑誌名: 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.

PMID 17899276  Dis Colon Rectum. 2007 Nov;50(11):1996-2000. doi: 10.10・・・
著者: Joshua R Karas, Selman Uranues, Donato F Altomare, Selman Sokmen, Zoran Krivokapic, Jiri Hoch, Ivan Bartha, Roberto Bergamaschi, Rectal Prolapse Recurrence Study Group
雑誌名: 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.

PMID 21160310  Dis Colon Rectum. 2011 Jan;54(1):29-34. doi: 10.1007/DC・・・
著者: G Salkeld, M Bagia, M Solomon
雑誌名: 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.
PMID 15449272  Br J Surg. 2004 Sep;91(9):1188-91. doi: 10.1002/bjs.464・・・
著者: F Cadeddu, P Sileri, M Grande, E De Luca, L Franceschilli, G Milito
雑誌名: 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.

PMID 22170252  Tech Coloproctol. 2012 Feb;16(1):37-53. doi: 10.1007/s1・・・
著者: H A Formijne Jonkers, N Poierrié, W A Draaisma, I A M J Broeders, E C J Consten
雑誌名: 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.
PMID 23406289  Colorectal Dis. 2013 Jun;15(6):695-9. doi: 10.1111/codi・・・
著者: Charles Evans, Andrew R L Stevenson, Pierpaolo Sileri, Mark A Mercer-Jones, Anthony R Dixon, Chris Cunningham, Oliver M Jones, Ian Lindsey
雑誌名: 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.

PMID 26163960  Dis Colon Rectum. 2015 Aug;58(8):799-807. doi: 10.1097/・・・
著者: Esther C J Consten, Jan J van Iersel, Paul M Verheijen, Ivo A M J Broeders, Albert M Wolthuis, Andre D'Hoore
雑誌名: 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.

PMID 26583661  Ann Surg. 2015 Nov;262(5):742-7; discussion 747-8. doi:・・・
著者: Fatma A Gultekin, Mark T C Wong, Juliette Podevin, Marie-Line Barussaud, Myriam Boutami, Paul A Lehur, Guillaume Meurette
雑誌名: 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.

PMID 25664713  Dis Colon Rectum. 2015 Mar;58(3):339-43. doi: 10.1097/D・・・
著者: C B RIPSTEIN
雑誌名: Am J Surg. 1952 Jan;83(1):68-71.
Abstract/Text
PMID 14903331  Am J Surg. 1952 Jan;83(1):68-71.
著者: C WELLS
雑誌名: Proc R Soc Med. 1959 Aug;52:602-3.
Abstract/Text
PMID 13843894  Proc R Soc Med. 1959 Aug;52:602-3.
著者: I R Berman
雑誌名: 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.

PMID 1535309  Dis Colon Rectum. 1992 Jul;35(7):689-93.
著者: Seung-Hyun Lee, Paryush Lakhtaria, Jorge Canedo, Yoon-Suk Lee, Steven D Wexner
雑誌名: 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.

PMID 21479778  Surg Endosc. 2011 Aug;25(8):2699-702. doi: 10.1007/s004・・・
著者: Jian-Hua Ding, Jorge Canedo, Seung-Hyun Lee, Sudhir N Kalaskar, Lester Rosen, Steven D Wexner
雑誌名: 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.

PMID 22595846  Dis Colon Rectum. 2012 Jun;55(6):666-70. doi: 10.1097/D・・・
著者: S W Chun, A J Pikarsky, S Y You, P Gervaz, J Efron, E Weiss, J J Nogueras, S D Wexner
雑誌名: 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.

PMID 15057581  Tech Coloproctol. 2004 Mar;8(1):3-8; discussion 8-9. do・・・

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