Abdominal approach for rectal prolapse

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					Abdominal approach for
   Rectal prolapse
      Leung Yu Wing
          TKOH
           Complete rectal prolapse
• Circumferential protrusion through the anus of all
  layers of the rectal wall




   2009 Nucleus Medical Media, Inc.
                         Epidemiology
• True incidence unknown
• Annual incidence in Finland quoted to be
  2.5/100, 000
• Male to female 1:6
• More common in the elderly




Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete
rectal prolapse. Scand J Surg. 2005;94(3):207-10
            Predisposing factors
•   Chronic constipation
•   Multiple vaginal delivery
•   Previous surgery, e.g. hysterectomy
•   Connective tissue disorder
             Associated anatomic features




Karulf RE, Madoff RD, Goldberg SM. Rectal Prolapse. Curr Probl Surg 2001;38:757-832.
                  Symptoms
•   Protruding rectum
•   Faecal incontinence 50-75%
•   Constipation 25-50%
•   Pain variable
•   Ulceration 10-25%
•   Bleeding
•   Incarceration, gangrene rare
http://emedicine.medscape.                                                            ACS Surgery Section 5 Chapter 36
com/article/2026460-
overview




                             World J Gastroenterol. 2010 June 7; 16(21): 2689-2691.
                    Workup
• Barium enema / Colonoscopy
  – Exclude other colonic lesions
  – Barium enema better demonstrate redundancy
  – Biopsy for rectal ulcer to exclude other pathology
• Video defaecography
                    Workup
• Anorectal manometry
  – Decrease in resting pressure in internal sphincter
  – Absence of anorectal inhibitory reflex
• Sitz marker study
  – Measure colonic transit to determine need for
    colonic resection
• Pudendal nerve terminal motor latency
  (PNTML)
  – Neurologic injury / dysfunction
                           Management
• Fibre and stool softener may
  alleviate constipation
• Surgery is the mainstay for
  treatment
• No study directly compare
  surgical and conservative
  management

Tou S, Brown SR, Malik AI, Nelson RL. Surgery for complete rectal prolapse in adults.
Cochrane Database Syst Rev. 2008: CD001758.
                              Management
• A number of procedures
  have been described
• Perineal approach for
  elderly frail patients
• Abdominal approach for fit
  patients

Brown AJ, Anderson JH, McKee RF, Finlay IG. Strategy for selection of type of operation for rectal
prolapse based on clinical criteria. Dis Colon Rectum 2004; 47: 103–107
Deen KI, Grant E, Billingham C, Keighley MRB. Abdominal resection rectopexy with pelvic floor
repair versus perianal rectosigmoidectomy and pelvic floor repair for full-thickness rectal
prolapse. British Journal of Surgery 1994;81(2):302–4.
               Management

• Abdominal approach
  – division of lateral ligament vs no division
  – suture vs prosthesis for rectopexy
  – rectopexy vs resection + rectopexy
  – open vs laparoscopic
          Division of lateral ligament
• 18 patients had posterior rectopexy, of whom
  10 had division of lateral ligament
• No recurrence
• No significant difference detected in
  constipation score



Mollen RM, Kuijpers JH, van Hoek F. Effect of rectal mobilisation and lateral sphincter
division on colonic and anorectal function. Diseases of the Colon and Rectum 2000;
43:1283–7.
         Division of lateral ligament
• A prospective randomized study of rectopexy
  with (n=14) or without (n=12) division of lateral
  ligaments
• Recurrence in the group with division vs without
  0% vs 33%
• In the division group, constipation increased from
  21.4% to 71.4% (pre-op to post-op)


Speakman CTM, Madden MV, Nicholls RJ, Kamm MA. Lateral ligament division during
rectopexy causes constipation but prevents recurrence: results of a prospective
randomized study. British Journal of Surgery 1991;78(12):1431–3.
                       Suture rectopexy
  • Recurrence rates
    3-9%
  • May produce new
    onset (15%) or
    worsened (50%)
    constipation

Carter AE. Rectosacral suture fixation for complete rectal prolapse in the elderly, the
frail and the demented. Br J Surg. 1983;70:522–523.
Aitola PT, Hiltunen KM, Matikainen MJ. Functional results of operative treatment of
rectal prolapse over an 11-year period: emphasis on transabdominal approach. Dis
Colon Rectum. 1999;42:655– 660.
                       Mesh rectopexy
• Wells procedure
• Fixation of rectum
  using an Ivalon
  sponge and
  transection of lateral
  ligaments



Wells C. New operation for rectal prolapse. Proc R Soc Med. 1959;52:602– 603.
Karulf RE, Madoff RD, Goldberg SM. Rectal Prolapse. Curr Probl Surg 2001;38:757-832.
                         Suture vs mesh
• A randomized trial of 31 Ivalon sponge rectopexy
  vs 32 suture rectopexy
• One recurrence in each group

                                     Ivalon sponge           Suture
  Post-op complications              19%                     9%
  Faecal incontinence                29%                     16%
  Post-op constipation               48%                     31%


Novell JR, Osborne MJ, Winslet MC, Lewis AA. Prospective randomized trial of Ivalon
sponge versus sutured rectopexy for full-thickness rectal prolapse. British Journal of
Surgery1994;81(6):904–6.
                 Ripstein procedure
•   Recurrence 2.3-5%
•   Morbidities 20%
•   Incontinence 28.3%
•   Constipation 45.7%



Schultz I, Mellgren A, Dolk A, Johansson C, Holmstrom B. Long-term results and
functional outcome after Ripstein rectopexy. Dis Colon Rectum. 2000;43:35–43.
McMahan JD, Ripstein CB. Rectal prolapse: an update on the rectal sling procedure.
Am Surg. 1987;53:37–40.
                         Ventral mesh
 • A systematic review of
   728 patients
 • Recurrence rate 3.4%
 • A decrease in
   constipation rate 23%.
 • However, new onset of
   constipation was
   14.4%
Samaranayake CB, Luo C, Plank AW, Merrie AE, Plank LD, Bissett IP. Systematic review
on ventral rectopexy for rectal prolapse and intussusception. Colorectal Dis.
2010;12:504–512.
                               Resection
• A randomized study on resection +
  suture rectopexy vs mesh rectopexy
• No recurrence
• Similar improvement in incontinence
• 33% in rectopexy alone became
  severely constipated post-op
• 3 complications in resection group (1
  in rectopexy alone group)
Luukkonen P, Mikkonen U, Jarvinen H. Abdominal rectopexy with sigmoidectomy
versus rectopexy alone for rectal prolapse: A prospective, randomized study. Internal
Journal of Colorectal Disease 1992;7(4):219–22.
                             Resection
• A case series of 16 patients had marlex mesh
  rectopexy vs 13 patients had sigmoidectomy with
  sutured rectopexy
                                    Rectopexy             Rectopexy +
                                    alone                 resection
Continence                          75%                   66.7%
Persisted constipation              100%                  20%
New constipation                    30.8%                 0%
Complications                                             1 small bowel
                                                          obstruction
Sayfan J, Pinho M, Alexander-Williams J, Keighley MR. Sutured posterior abdominal
rectopexy with sigmoidectomy compared with Marlex rectopexy for rectal prolapse. Br
J Surg. 1990;77:143–145.
             Laparoscopic rectopexy
• A case control study of 111 patients underwent
  laparoscopic rectopexy, 86 patients underwent open
  repair
                        Laparoscopic repair         Open repair
Recurrence              3.9%                        4.7%
Post-op                 30%                         33%
incontinence
Constipation            35%                         53%
Hospital stay           3.9                         6.0
Kariv Y, Delaney CP, Casillas S, et al. Long-term outcome after laparoscopic
and open surgery for rectal prolapse: a case-control study. Surg Endosc.
2006;20:35– 42.
               Laparoscopic rectopexy
• 40 patients randomized to
  laparoscopic vs open group
• Laparoscopy group:
     – less pain and narcotic requirement
     – better mobility
     – shorter hospital stay
     – Estimated saving of 357 pounds
       per patient
Salkeld G, Bagia M, Solomon M. Economic impact of laparoscopic versus open abdominal
rectopexy. British Journal of Surgery 2004;91(9):1188–91.
Solomon MJ, Young CJ, Eyers AA, Roberts RA. Randomized clinical trial of laparoscopic versus
open abdominal rectopexy for rectal prolapse. British Journal of Surgery 2002;89(1):35–9.
                                 Robotic




Moorthy K, Kudchadkar R, et al. Robotic assisted rectopexy. Am J Surg. 2004;187:88 –92.
                                Robotic
• 14 robot assisted laparoscopic
  rectopexy vs 19 conventional
  laparoscopic rectopexy
• Similar conversion rates 3-5%
• Similar constipation, continence
• Mean operating time 39min longer
• Costs US$745.09 higher

Heemskerk J, de Hoog DE, van Gemert WG, Baeten CG, Greve JW, Bouvy ND. Robot-
assisted vs conventional laparoscopic rectopexy for rectal prolapse: a comparative
study on costs and time. Dis Colon Rectum. 2007;50:1825–1830..
                 Conclusion
• Abdominal approach
  – Division of lateral ligament vs no division
    • Division of lateral ligament may have less
      recurrence, but more constipation
  – Suture vs prosthesis for rectopexy
    • Prosthesis may have more complications, more
      constipation
                 Conclusion
• Abdominal approach
  – Rectopexy vs resection + rectopexy
    • With resection, there is less constipation, but
      slightly more complications
  – Open vs laparoscopic
    • Laparoscopic approach has comparable results
    • Laparoscopic approach decreases hospital stay
      and costs
                         PROSPER trial
• 293 patients from 2/2001 to 4/2008 were
  randomised between
    – (a) abdominal and perineal and
    – (b) suture vs resection rectopexy for those receiving
      abdominal procedure or
    – (c) Altemeier’s vs Delorme’s for those receiving
      perineal procedures
• Primary outcome were defaecatory performance
  and QOL, secondary outcome were operative
  mortality / morbidity and recurrence
http://www.birmingham.ac.uk/research/activity/mds/trials/bctu/trials/coloproctolo
gy/prosper/index.aspx
Q&A
                                  Workup
• In 26 patients of rectal prolapse, EMG and
  pudendal nerve terminal motor latency were
  performed before Ripstein rectopexy
• Anal continence was improved, but was not
  predicted by pre-op EMG / PNTML



Schultz I, Mellgren A, Nilsson BY, Dolk A, Holmstrom B. Preoperative electrophysiologic
assessment cannot predict continence after rectopexy. Dis Colon Rectum.
1998;41:1392–1398.
                                Workup
• 45 patients underwent anal manometry and
  PNTML before rectal prolapse repair
• Pre-op squeeze pressure >60mmHg vs lower
  Better post-op fecal continence 10% vs 54%
• PNTML was not predictive of post-op
  continence



Glasgow SC, Birnbaum EH, Kodner IJ, Fleshman JW, Dietz DW. Preoperative Anal
Manometry Predicts Continence After Perineal Proctectomy for Rectal Prolapse. Dis
Colon Rectum. 2006;49:1052-1058.
            Division of lateral ligament
• 20 patients randomized, 11 underwent marlex
  rectopexy with division of lateral ligament, 9
  patients without.
• Continence improved in both groups, post-op
  symptoms improved significantly in those
  without division compared with those with
  division.


Selvaggi F, Scotto di Carlo E, Silvestri L, Festa L, Piegari V. Surgical treatment of rectal
prolapse: a randomised study (Abstract). British Journal of Surgery 1993;80:S89.
          No rectopexy vs rectopexy
• Multicentre randomized controlled trial of 251
  patients
• 116 no rectopexy compared with 136
  rectopexy, sigmoidectomy added if
  constipation
• No sig difference in complication
• Significant difference in 5 year recurrence
  8.6% vs 1.5%
Karas JR, Uranues S, Altomare DF, et al. 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
          Alternative mesh materials
• 2 trials comparing polyglycolic acid mesh (n=37) vs
  polyglactin (n=30) / polypropylene (n=17) mesh
• 1 recurrence in polyglycolic acid mesh
• Residual incontinence
     – 20% for polyglycolic acid mesh
     – 35% for polyglactin mesh


Winde G, Reers B, Nottberg H, Berns T, Meyer J, Bunte H. Clinical and functional results
of abdominal rectopexy with absorbable mesh-graft for treatment of complete rectal
prolapse. European Journal of Surgery 1993;59(5):301–5.
Galili Y, Rabau M. Comparison of polyglycolic acid and polypropylene mesh for
rectopexy in the treatment of rectal prolapse. European Journal of Surgery
1997;163(6):445–8.
Marlex mesh rectopexy
                             Resection
• 18 patients randomized to rectopexy alone or
  with sigmoidectomy
• 77.8% in rectopexy alone group, 22.2% in
  sigmoidectomy group complained of severe
  constipation




Mckee RF, Lauder JC, Poon FW, Aitchison MA, Finlay IG. A prospective randomized
study of abdominal rectopexy with and without sigmoidectomy in rectal prolapse.
Surgery, Gynecology and Obstretics 1992;174(2):145–8.
                              Resection
• 12 patients with no preexisting constipation
  had laparoscopic rectopexy without resection
• No complications
• No recurrence
• Only 1 patient previously had irritable bowel
  syndrome developed significant constipation


Hsu A, Brand MI, Saclarides TJ. Laparoscopic rectopexy without resection: a
worthwhile treatment for rectal prolapse in patients without prior constipation. Am
Surg. 2007;73:858–861.
               Laparoscopic rectopexy
• Retrospective study of 13
  by open technique and 8 by
  laparoscopic approach
• Incontinence sig. improved
  in both groups
• Post-op stay was shorter in
  laparoscopic group
Boccasanta P, Rosati R, Venturi M, Montorsi M, Cioffi U, De Simone M, et
al.Comparison of laparoscopic rectopexy with open technique in the treatment of
complete rectal prolapse: clinical and functional results. Surgical Laparoscopy and
Endoscopy 1998;8(6):460–5.
             Laparoscopic rectopexy
• A case series of 109 patients had laparoscopic
  ventral rectopexy for rectal prolapse
• Conversion 3.7%
• Recurrence 3.7%
• No mortality, minor morbidity 7%
• Mean hospital stay 5.14 days
D’Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal
prolapse: surgical technique and outcome for 109 patients. Surg Endosc.
2006;20:1919 –1923.
DHoore A, Cadoni R, Penninckx F (2004) Long-term outcome of laparoscopic
ventral rectopexy for total rectal prolapse. Br J Surg 91: 1500–1505
             Laparoscopic rectopexy




D’Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal
prolapse: surgical technique and outcome for 109 patients. Surg Endosc.
2006;20:1919 –1923.
             Laparoscopic rectopexy




D’Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal
prolapse: surgical technique and outcome for 109 patients. Surg Endosc.
2006;20:1919 –1923.
             Laparoscopic rectopexy




D’Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal
prolapse: surgical technique and outcome for 109 patients. Surg Endosc.
2006;20:1919 –1923.
                    Anterior resection
• In a review of 113 patients
• Operative morbidity 29%, including 3
  anastomotic leakage
• Recurrence rate at 2, 5, 10 years were 3%, 6%,
  12%
• Also a low pelvic anastomosis in those with
  borderline continence may cause complete
  loss of control
Cirocco WC, Brown AC. Anterior resection for the treatment of rectal prolapse: a 20-
year experience. Am Surg. 1993;59:265–269.
Schlinkert RT, Beart RW Jr, Wolff BG, Pemberton JH. Anterior resection for complete
rectal prolapse. Dis Colon Rectum. 1985;28:409–412.
                                  Robotic
• 2 mesh rectopexy, 4 sutured
  rectopexy + sigmoidectomy
  were performed
• No mortality
• 1 conversion
• 1 rectal tear with temporary
  colostomy
• No recurrence
Ayav A, Bresler L, Hubert J, Brunaud L, Boissel P. Robotic-assisted pelvic organ
prolapse surgery. Surg Endosc. 2005;19:1200–1203.
                                 Robotic
• 6 cases of robotic assisted
  rectopexy
• No conversion
• No mortality or major
  complications
• No recurrence
• No reports of constipation
• Mean operative time 127min
Moorthy K, Kudchadkar R, et al. Robotic assisted rectopexy. Am J Surg. 2004;187:88 –92.
                          Quality of life
•   54 patients underwent laparoscopic rectopexy
•   No mortality, morbidity 5.5%
•   7.4% recurrence
•   20.3% constipation
•   Continence improved in 72.4%
•   QOL rated satisfactory in 96%
Auguste T, Dubreuil A, Bost R, Bonaz B, Faucheron JL. Technical and functional results
after laparoscopic rectopexy to the promontory for complete rectal prolapse.
Prospective study in 54 consecutive patients. Gastroenterol Clin Biol. 2006
May;30(5):659-63.
Anal encirclement
Altemeier’s procedure
Delorme’s procedure
Treatment algorithm

				
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