specifically referred for perineal procedures for rectal prolapse are sent because of their high risk for abdominal surgery. A careful evaluation of the patient’s medical history and risk factors for surgery must be performed.
Second, because patients with prolapse can manifest a wide range of dysfunction from incontinence to constipation, the understanding of the pelvic floor physiology of each individual is essential. A common battery of tests may include electromyography, anal manometry, and defecography. Paradoxical puborectalis contrac- tion is often found during preoperative evalua- tion with defecography. In one series, 12 of 61 patients (20%) with rectal prolapse had non- relaxing puborectalis prior to surgery, and the association with constipation was significant.2 Although some authors have noted a good cor- relation between electromyography (EMG) and defecography in identifying paradoxical pub- orectalis,3others have found a poor correlation.
Third, it is important to evaluate the colon for sources of constipation. Endoscopic examina- tion of the colon is an important part of the workup, specifically in the elderly, to identify pathologic sources of rectal prolapse (requiring a different form of intervention) and synchro- nous pathology. A colon transit study is also indicated to identify patients with colonic dys- motility as a primary cause of constipation. In a series comparing abdominal rectopexy with and without sigmoid resection, 54% of patients in both groups had prolonged transit studies before surgery.4It was noted in this study, after surgery, that patients with resection had a lower incidence of constipation than patients without resection. It was concluded that angulation of Constipation and rectal prolapse frequently
coexist. Estimates of preoperative constipation range from 30% to 67% in prospective studies.1 It is not clear whether constipation results in rectal prolapse, or prolapse results in constipa- tion due to a functional outlet obstruction. Many patients report improvement in bowel function after surgery for rectal prolapse. Conversely, some patients with normal bowel function prior to surgery for rectal prolapse complain of con- stipation after surgery. Nevertheless, perineal procedures are often performed for patients with constipation and rectal prolapse.
Perineal Approaches
Not all patients are able to withstand the stress of an abdominal procedure. In fact, the condi- tions that may predispose patients to rectal pro- lapse, such as increased age, malnutrition, and pulmonary disease, may prohibit performing an abdominal approach to repair this problem.
Perineal approaches offer an alternative form of treatment that generally places the patient under less stress in the operative period and may be better tolerated.
Evaluation
The importance of preoperative evaluation prior to embarking of any form of surgical interven- tion for rectal prolapse cannot be overempha- sized. Three specific areas are assessed before perineal surgery for patients with constipation and rectal prolapse. First, many of the patients
20
Perineal Procedures for Rectal Prolapse
Richard E. Karulf and Karim Alavi
193
the bowel or kinking due to redundant sigmoid colon could be the original cause of the consti- pation before surgery and was unrelieved after surgery.
Anal Encirclement Procedure
In 1891, Thiersch initially described encir- clement of the anus with silver wire for treat- ment of incontinence and rectal prolapse.5,6 It was hoped that the wire would produce an area of fibrosis around the anus that would act as a passive support for the pelvic floor (Fig. 20.1).
Unfortunately, not only did the wire fail to provoke the desired fibrosis, but it also produced unwanted complications, including ulceration, erosion, breakage, and fecal impaction.
Surgeons have attempted to modify the encir- clement technique by using other materials including fascia, tendon, nylon, polypropylene mesh, Mersilene®, and Teflon®. These materials have shown less of a tendency to break and have had fewer complications than were noted with the silver wire.
The disadvantage of encirclement procedures
is that, in most cases, the ring is placed in the subcutaneous space and does not support the levators. As a result, this technique does not cure prolapse; it merely hides it away from view and should be regarded as a palliative procedure. The advantage of encirclement procedures is that they can be performed under local or spinal anesthesia and they have minimal impact on even the poorest risk patient. The disadvantage is that if the rectum prolapses through the ring, it may incarcerate necessitating an emergency operation.
Notaras7 described one interesting variation of the Thiersch anal encirclement procedure (Fig. 20.2). In this variation, a ribbon of polypropylene mesh is placed around the rectum at the level of the puborectalis. The goal of this procedure is to support both the anorectal angle and the anal canal. Due to the more extensive dissection that was required with this technique, general anesthesia is often required. Limited information is available about recurrence rates with this technique.
One other unusual technique used an Angelchik prosthesis to encircle the distal rectum; this device was at one point in time popular for the treatment of esophageal reflux.8 The technique is no longer performed, because the device was withdrawn from the market when
Figure 20.1. Anal encirclement. Also known as the Thiersch procedure, this operation has been performed with the use of many types of mate- rial. Note that the ring is placed in the subcutaneous (perianal) tissue and offers no support to the levators.(From Karulf RE, Madoff RD, Goldberg SM.
Rectal prolapse. Curr Probl Surg 2001;38:771–832, with permission from Elsevier.)
Figure 20.2. Notaras variation of the Thiersch procedure. The ring of foreign material is placed around the anorectal musculature at the level of the puborectalis muscle, thus supporting both the anorectal angle and the anal canal.(From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001;38:771–832, with permission from Elsevier.)
reported the results of a one-stage procedure with 106 patients over a 19-year period. There were no postoperative deaths and only three recurrences in their series. Their results were especially impressive considering the patients were older (average age: 62 years) than the patients in most series of the time, and the majority of the patients had documented psy- chiatric disease (52%).
The technique of the perineal rectosig- moidectomy is thought to be difficult to concep- tualize. With the rectum prolapsed, there are two full-thickness layers of the bowel wall. The outer layer is distal and attaches to the anal canal, while the inner layer is in continuity with the proximal bowel. An incision is made through the outer layer, 2 to 4 cm above the dentate line, which straightens the rectum and sigmoid colon.
With traction on the bowel, the mesorectum is divided with suture ligation of the vessels. A sur- prising amount of proximal rectum and sigmoid colon can be prepared for resection with this technique. When, in the judgment of the surgeon, sufficient bowel has been devascular- ized, the inner layer of bowel is transected and a hand-sewn or stapled anastomosis is created between the two cut ends of bowel. As originally described, Altemeier opened the peritoneal cul-de-sac and obliterated what he considered to be a sliding hernia sac. He also reefed the it fell into disfavor due to complications. The
device was placed above the levators in a series of eight elderly patients with rectal prolapse.
With the exception of this one nuance, it was similar to other encirclement procedures.
Results showed one death on postoperative day 10 due to a stroke, and one patient with pelvic sepsis in whom the prosthesis was removed.
There were no reports of recurrence, morbidity, or mortality in the six remaining patients.
Another version of anal encirclement is the Gant-Miwa procedure, which has been described in Japan. In this procedure, an absorbable suture is used to create dozens of tags of mucosa and submucosa on the surface of the prolapsed rectum. The rectum is then returned to its normal anatomic position and a nonabsorbable purse-string suture is placed around the anus. A recent review of this procedure lists low compli- cation and recurrence rates, although it is not widely practiced outside of Japan.9
Perineal Rectosigmoidectomy
Although first performed by Mickulicz10in 1889 and later advocated by Miles11 in 1933 and Gabriel12 in 1948, the perineal rectosigmoidec- tomy is most commonly associated with Altemeier (Fig. 20.3). In 1971, Altemeier et al13
a b c d
Figure 20.3. Perineal rectosigmoidectomy. With the rectum prolapsed, the outer rectal tube is incised circularly (a) and unfolded (b). The mesorec- tum is serially ligated and divided (c). When all redundancy has been removed, the inner tube is divided, which completes the resection (d).From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001;38:771–832, with permission from Elsevier.
puborectalis together anterior to the rectum and performed a sutured anastomosis. Other sur- geons often omit these two additional technical points due to lack of proven benefit.
One variation on Altemeier’s technique employs an intraluminal stapling device to create the anastomosis (Fig. 20.4).14Bennett and Geelhoed15reviewed the subject and advocated the use of a stapler in creating the anastomosis, for three reasons. First, it simplifies the anasto- mosis. Second, there can be a more extensive resection, since the anastomosis is completed inside the anus. Third, in their opinion, the nar- rowing that is seen after stapled anastomosis may prevent the later need for sphincter plica- tion. However, superior functional results have never been documented with stapled compared to hand-sewn anastomosis for this procedure.
Because of its minimally invasive nature, per- ineal rectosigmoidectomy has been suggested as an alternative for elderly or high-risk patients. A series at the University of Minnesota reviewed the results of perineal rectosigmoidectomy in 114 patients of a median age of 78 years.16There were no deaths and a 12% complication rate;
hospital stay averaged 4 days. Only 11 of the 104 patients (11%) who were available for follow- up developed recurrent full-thickness rectal prolapse. In a second series from Arizona, 72 patients over age 70 were treated with perineal excision of rectal prolapse.17In this series, nine of the 72 patients presented with acute incarcer- ated rectal prolapse. Two anastomotic leaks were
noted, both in the acutely incarcerated group, both of which required a diverting colostomy.
The length of stay averaged 7 days. In a follow- up of 6 months to 9 years (average 48 months), there were no deaths, and eight complications were noted (11%). Four of the 72 patients, had recurrent full-thickness rectal prolapse (5.6%) and another four had prolapse limited to the mucosa. These studies provide evidence that even in elderly or high-risk patients, rectal prolapse can be treated with perineal rectosig- moidectomy with minimal morbidity.
Other authors have reported their results with the Altemeier procedure with less encouraging results. A high rate of recurrence (58%) was reported in the St. Mark’s series, with half of these in the first 3 years.18Other authors report a recurrence rate as high as 60% with perineal rectosigmoidectomy.19It is not clear why these early reports are at odds with reports in recent years. It is clear that the recurrence rate is linked to the length of follow-up, and more recent reports have emphasized the use of this tech- nique in older and high-risk patients. It is possi- ble that if the early reports had a greater percentage of younger patients, the recurrence rates could be unfavorably skewed.
In addition, these reports from 50 years ago used a technique in which the colorectal anasto- mosis was hand sewn well outside of the anal canal. The anastomosis was then reduced through the sphincters. By allowing this amount of redundancy, the patients were leaving the
a b c
d e
Figure 20.4. Variation of Altemeier’s technique. The anastomosis may be performed with an intraluminal stapling device (a–e).From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001;38:771–832, with permission from Elsevier.
described by Delorme22 in 1900, is still per- formed today (Fig. 20.5). The procedure includes a stripping of the mucosa of the prolapsed rectum and sutured plication of the remnant bare muscle, collapsing the wall like an accor- dion. The mucosa is then reapproximated to seal the anastomosis.
The main advantage of the Delorme proce- dure is its minimal physiologic impact. The lack of an abdominal incision and avoidance of the peritoneal cavity are key factors. It can be per- formed under local anesthesia, if needed, on even the highest risk patients. It is ideal for a low or a small prolapse. Frail or elderly patients with a limited life expectancy, who have a sympto- matic rectal prolapse, are best suited to this procedure.
There are many disadvantages of the mucosal sleeve procedure. The procedure requires a dis- section of the mucosa from the muscle wall.
More importantly, the procedure does not fix the rectum to the sacrum or repair the pelvic floor, and the pleated muscle at the anal verge provides a false sense of security when considering the potential for recurrence. Even in favorable series, the recurrence rate for mucosal sleeve resection is higher than the rate for most contemporary operating room with an inadequate resection.
More recent articles have described creating the anastomosis closer to the sphincter complex and allowing more tension on the repair. These small technical points and the difference in patient selection may account for the difference in recurrence rates.
One interesting finding, noted in both the Uni- versity of Minnesota and the Arizona series, was an improvement in continence after surgery. In the Minnesota series, 67 of the 104 patients were incontinent to solid or liquid stool prior to surgery; 56 of these individuals underwent rec- tosigmoidectomy as a sole procedure and 26 (46%) regained full control. The remaining 11 patients had levatoroplasty at the time of rec- tosigmoidectomy and 10 improved (91%) with seven becoming fully continent (64%). In the Arizona series, 54 of 72 patients were incontinent to feces and all patients were incontinent to flatus prior to surgery. Following surgery, which included perineal excision of the rectum and posterior levator approximation to re-create the anorectal angle, 48 patients (67%) had regained continence of both flatus and feces.A study at the Cleveland Clinic Florida analyzed 20 consecutive elderly patients of a mean age of 82 years who underwent perineal rectosigmoidectomy for full- thickness rectal prolapse.20Detailed functional assessment and physiologic testing were per- formed before and after surgery. There was one death, one major complication, and no recur- rences in an average of 26 months of follow-up.
Before surgery, six of 10 patients had prolonged pudendal nerve terminal motor latency (PNTML) values (longer than 2.5 msec). Conti- nence scores improved, on an average, from 14.5 before surgery to 8.4 after surgery. It is interest- ing to note that continence scores improved in four of the six patients with evidence of at least unilateral neuropathy. This finding suggests that a prolonged PNTML may not be an accurate predictor of postoperative continence. The low recurrence rate was undoubtedly due to the very short follow-up, as a subsequent series of 61 patients from Cleveland Clinic Florida reported a recurrence rate of 12.5%.21
Mucosal Sleeve Procedure
Unlike many other operations for prolapse that were performed at the beginning of the 20th century, the mucosal sleeve resection, originally
Figure 20.5. Resection of mucosal sleeve and plication of the rectal wall (Delorme procedure). This operation involves a total mucosal stripping of the prolapsed segment and its plication in an accordion-like fashion by a series of stitches.From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001;38:771–832, with permission from Elsevier.
abdominal procedures or rectosigmoidectomy.
While a focus on patient selection may improve the results,23selection criteria alone are not the answer. Patients who are seeking a durable repair for rectal prolapse should look elsewhere for a solution.
Perineal Rectopexy
The earliest versions of this procedure were described by Lockhart-Mummery in 1910.
Packing the retrorectal space with gauze was found to have a prohibitively high recurrence rate. Inserting a Mersilene mesh high in the retrorectal space and suturing the edges to the sides of the rectum modified the technique to improve the recurrence rate.24 Mobilization of the rectum and placement of mesh was per- formed through a posterior perineal approach, occasionally removing the coccyx to improve exposure (Fig. 20.6). In a series of 22 women with a mean age of 75 years undergoing this proce- dure, there were no deaths or significant mor- bidity and only one recurrence.
After Surgery
Patients who had no difficulty with defecation prior to surgical management of rectal prolapse have developed constipation after surgery. In fact, the development of constipation is the single most common problem after fixation rectopexy.25The cause of the constipation after perineal procedures is not clear. Two theories dominate the discussion: decreased rectal com- pliance and dysmotility.
Decreased Compliance
Compliance is a measure of the elasticity of tissues. Scarring of the rectum during mucosal sleeve resections26 and mesh rectopexy27 may reduce compliance and therefore make passage of stool more difficult for some patients.
Decreased compliance is also noted with per- ineal rectosigmoidectomy when a compliant rectum is replaced with a less distensible sigmoid colon.28
One note regarding compliance warrants mention. Attempts have been made to apply the concept of compliance to discussions of the physiology of defecation. However reasonable this is in theory, practical application is difficult because, in the absence of a Hartmann pouch, the rectum is an open-ended tube. As a result, direct measurements of compliance are not possible with current technology. Measure- ments using air- or fluid-filled condoms will, at best, approximate the compliance of the rectum.
Abnormal Motility
In a review, 12 patients complaining of constipa- tion after Orr-Loygue rectopexy were compared with 12 patients with full-thickness rectal pro- lapse and 10 healthy volunteers.29The rectopexy group was similar to the other two groups in terms of demographics and preoperative func- tion. However, the rectopexy group had lower weekly stool frequency and a higher prevalence of abdominal pain. The authors also reported prolonged global, right, and left colonic transit times in the rectopexy group, but similar rec- tosigmoid transit times and manometric param- eters of the anal sphincter in all three groups.
They suggested that the obstruction was
Figure 20.6. Perineal rectopexy. Through a posterior perineal incision, the rectum is widely mobilized. A patch of Mersilene mesh is sewn to the sacrum. The sides of the rectum will then be sutured to its edges.From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001;
38:771–832, with permission from Elsevier.
12. Gabriel WB. The Principles and Practices of Rectal Surgery, 4th ed. Springfield, IL: Charles C Thomas, 1948.
13. Altemeier WA, Culbertson WR, Schowengerdt C, Hunt J. Nineteen years’ experience with the one-stage perineal repair of rectal prolapse. Ann Surg 1971;173:
993–1006.
14. Vermeulen FD, Nivatvongs S, Fang DT, Balcos EG, Goldberg SM. A technique for perineal rectosig- moidectomy using autosuture devices. Surg Gynecol Obstet 1983;156:84–86.
15. Bennett BH, Geelhoed GW. A stapler modification of the Altemeier procedure for rectal prolapse. Experi- mental and clinical evaluation. Am Surg 1985;51:
116–120.
16. Williams JG, Rothenberger DA, Madoff RD, Goldberg SM. Treatment of rectal prolapse in the elderly by per- ineal rectosigmoidectomy. Dis Colon Rectum 1992;35:
830–834.
17. Ramanujam PS, Venkatesh KS, Fietz MJ. Perineal exci- sion of rectal procidentia in elderly high-risk patients.
A ten-year experience. Dis Colon Rectum 1994;37:
1027–1030.
18. Porter NH. Collective results of operations for rectal prolapse. Proc R Soc Assoc Med 1962;55:1087–1091.
19. Hughes ESR. In discussion on rectal prolapse. J R Soc Med 1949;42:1007–1011.
20. Johansen OB, Wexner SD, Daniel N, Nogueras JJ, Jagelman DG. Perineal rectosigmoidectomy in the elderly. Dis Colon Rectum 1993;36:767–772.
21. Agachan F, Reissman P, Pfeifer J, Weiss EG, Nogueras JJ, Wexner SD. Comparison of 3 perineal procedures for the treatment of rectal prolapse. South Med J 1997;
90(9):925–932.
22. Delorme R. Sur le traitement des prolapssu du rectum totaux pour l’excision de la musqueuse rectale ou rectocolique. Bull Mem Soc Chir Paris 1900;26:498–
499.
23. Sielezneff I, Malouf A, Cesari J, Brunet C, Sarles JC, Sastre B. Selection criteria for internal rectal prolapse repair by Delorme’s transrectal excision. Dis Colon Rectum 1999;42:367–373.
24. Wyatt AP. Perineal rectopexy for rectal prolapse. Br J Surg 1981;68:717–719.
25. Gordon PH, Hoexter B. Complications of the Ripstein procedure. Dis Colon Rectum 1978;21:277–280.
26. Plusa SM, Charig JA, Balaji V, Watts A, Thompson MR.
Physiological changes after Delorme’s procedure for full-thickness rectal prolapse. Br J Surg 1995;82:1475–
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27. Duthie GS, Bartolo DC. Abdominal rectopexy for rectal prolapse: a comparison of techniques. Br J Surg 1992;
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28. Farouk R, Duthie GS. The evaluation and treatment of patients with rectal prolapse. Ann Chir Gynaecol 1997;86:279–284.
29. Siproudhis L, Ropert A, Gosselin A, et al. Constipation after rectopexy for rectal prolapse. Where is the obstruction? Dig Dis Sci 1993;38:1801–1808.
functional, rather than anatomic, and that the source of the denervation may have been inci- dental injury of the autonomic parasympathetic innervation of the left colon and rectum. They concluded that constipation following rectopexy seems to be related to acquired sigmoid motility disturbances above the rectopexy, rather than to anorectal emptying.
Conclusion
There is a strong association between rectal pro- lapse and constipation. Perineal procedures to correct the prolapse may improve preexisting constipation. Modern series show that perineal rectosigmoidectomy for correction of rectal prolapse can be performed in even high-risk patients with a low recurrence rate and minimal morbidity.
References
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