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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Rectal prolapse

, M.D. and , M.D.

Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Fl, U.S.A.

Definition, pathogenesis

Definition

Rectal prolapse (procidentia)

  • is a full thickness, circumferential intussusception of the entire rectal wall through the anal canal resulting in part of the rectum remaining intermittently or occasionally permanently distal to the anus. The latter condition is known as third degree prolapse and the former state as second degree.

Internal intussusception

  • is invagination of part or the entire rectum into itself without any external component, also known as 1° rectal prolapse

Pathogenesis

Etiologic factors: 1) congenital, 2) acquired.

At the beginning of the century Moschcowitz (1) described the anatomical basis for a rectal prolapse as a deficient pelvic floor through which the rectum herniates. This theory was that a redundant sigmoid colon lying within the deep pelvic sac, together with the resulting acute rectosigmoid junction, caused the patient to strain excessively to evacuate. Thus, the hypothesis continued, the eventual prolapse was the result of herniation through the weakened pelvic floor.

A latter concept suggested that rectal prolapse was actually a circumferential 2° or 3° intussusception (2). Complete circumferential intussusception usually starts 6–8 cm from the anal verge but can continue through the anal canal (3).

Predisposing and associated anatomical and functional factors:

Anatomical factors include female sex, redundant rectosigmoid, deep pouch of Douglas, patulous anus (weak internal sphincter), diastasis of levator ani muscle (defects in pelvic floor), lack of fixation of rectum to sacrum. Functional factors include poor bowel habits (chronic constipation), neurologic disease including congenital anomaly, cauda equina lesion, spinal cord injury, and senility.

The majority of patients are women (4) and peak occurrence is in the sixth decade of life. Rectal prolapse is relatively uncommon in men; moreover they usually present when they are less than 50 years of age.

Diagnosis

The patient will usually present with a protrusion (75%), and in about 70% of cases, coexisting fecal incontinence; almost 50% of patients have a history of constipation (4). The incontinence becomes more severe as the protrusion increases in degree. Dilatation of the canal by the mass results in further relaxation of the sphincter muscles and increased prolapse (5). Bleeding per rectum, discharge of mucus, or both, are common additional complaints. When an individual's symptoms are suggestive of rectal prolapse, having the patient sit on the toilet and bear down to feign evacuation is often the only means by which the rectal prolapse can be visualized.

It is important to evaluate the tone and contractility of the sphincter mechanism. If sphincter tone is poor or if the anus is patulous, functional results after repair may be suboptimal. Alternatively, if the patient has relatively good sphincter tone and contractility, good bowel control can be ultimately anticipated. As occasionally a polyp or carcinoma of the rectum or sigmoid colon may be the “lead point” for an intussusception, an endoscopic examination should be performed. However ultimately, radiologic study of the rectum by means of defecography is most effective for identifying internal intussusception and other defecatory disorders.

Differential diagnosis

A protruding mass of hemorrhoidal tissue tends to be lobular as compared to the circular lining in rectal prolapse. Specifically the folds between the mucosal layers in hemorrhoidal prolapse are radial whereas in rectal prolapse they are circumferential. It is important to distinguish full thickness prolapse from mucosal prolapse because treatment of the two conditions is very different.

Therapy

Management of rectal prolapse is surgical; over 100 different procedures have been described. The existence of so many surgical options is attestation to the lack of uniform success associated with any one single procedure. Since no procedure is a panacea, the operation selected should be matched to the physiologic condition of the patient.

Transabdominal

Transabdominal repairs involve rectal fixation, rectal resection or a combination of resection and fixation. Attachment of the rectum to the sacrum can be performed using foreign material or sutures although the lateral rectal attachments can be achieved to the sacral periosteum without foreign material.

The primary advantages of a transabdominal procedure are the lower recurrence rates and the associated improvements in incontinence as well as the preservation of a rectal reservoir. Disadvantages are that they are a more invasive procedures and do have an associated risk of postoperative sexual dysfunction in males.

Anterior rectopexy (Ripstein procedure)

The rectum is completely mobilized posteriorly. A loose sung of mesh is wrapped around the anterior wall of the rectum and sutured to the sacrum.

Results: Recurrence varies form 0 to 10% (6, 7). Sling complications are noted in as many as 16.5% of patients with a 4% reoperation rate.

Posterior sling rectopexy (Wells procedure)

After posterior rectal mobilization and fixation of a mesh to the sacral hollow, the mesh is wrapped around the lateral aspects while the anterior rectal wall is left free to prevent stricture.

Results: Recurrence rates for anterior and posterior rectopexy are similar. However the rate of stricture and therefore postoperative constipation may be lower after posterior than after anterior rectopexy.

Anterior resection without fixation

After anterior resection the rectum becomes secondarily scarred and therefore adherent to the sacrum.

Advantages: removal of the redundant colon may prevent volvulus and torsion and may ameliorate some bowel complaints, especially constipation.

Disadvantages: Risk for anastomotic leak.

Results: Recurrence rate 9% (8). Deterioration of continence has been reported in 10–20% (9) of patients.

Resection with sacral fixation

Fixation of the distal rectal segment to the sacrum with redundant sigmoid extirpation.

Results: Initial reports stated recurrence rates of 2–9% (1012). Bowel control is more likely to be improved when compared to other methods. The procedure is comparable to rectopexy with respect to operative morbidity but postoperative constipation is less likely (13). Division of the lateral ligaments decrease recurrence rates but increase the incidence of postoperative constipation.

Suture Rectopexy

Perhaps the simplest abdominal approach is rectopexy. The rectum is mobilized distally down to the levator ani muscles. The mesentery of the rectum and the muscularis are secured to the sacral fascia or bone.

Results: Recurrence rates are reported in 2–5% (14, 15). However a redundant sigmoid colon may at least theoretically cause the onset of or exacerbate preexisting constipation.

Laparoscopy

Sutured rectopexy, mesh rectopexy, and anterior resection or resection rectopexy are all technically feasible laparoscopic approaches. So far controlled trials have not been performed and long-term recurrence data are not yet available. Small series suggest that morbidity and short term recurrence rates are similar to these reported by laparotomy.

Perineal procedures

Perineal procedures are associated with a higher recurrence rate than abdominal procedures. In addition postoperative incontinence may be exacerbated (16). However the benefits are related to avoiding a laparotomy and include a very low morbidity and negligible disability. These operations can be done under general, regional or occasionally local anesthesia.

Altemeier operation (perineal proctosigmoidectomy)

Perineal resection of the full thickness of the prolapsed segment with coloanal anastomosis.

Results: Recurrence rates can reach up to 50%. Additional plication of the levator ani muscles seems to be associated with a lower incidence of recurrence and better functional outcome (1720). The addition of a colonic J pouch has been attempted but no results have been reported to date.

Delorme Procedure

Unlike the perineal rectosigmoidectomy the dissection is within the submucosal layer. The mucosa and the submucosa are excised and the denuded muscularis is longitudinally pleated prior to effecting the anastomosis.

Results: Recurrence varies from 7 to 22% (2124).

Encirclement procedures

These operations are no longer used as they fail to eliminate the prolapse or to improve incontinence. Moreover high rates of infection, implant extrusion and stenosis with associated prolapse incarceration have been noted.

Conclusion

Surgical approaches to rectal prolapse will continue to be controversial unless a convincing control led trial demonstrates superiority of a single technique. Most of the evidence for the surgical treatment of rectal prolapse is derived from case series (Grade C). There are only few studies with a non-randomized concurrent cohort setting (Grade C) or a randomized controlled setting (Grades A and B). Most of the Grade A and B trials have focused upon comparing rectopexy to resection rectopexy or comparing various methods of rectopexy.

The treatment of choice is an abdominal procedure (preferably resection rectopexy) due to the fact that the recurrence rates are lower and continence is more likely to be restored than after other operations. Although perineal operations may have higher recurrence rates they are also much less invasive. These latter surgeries are well chosen for the elderly patients with comorbidities in whom an abdominal approach carries a prohibitively high operative risk. One must match the operation to the patient, balancing morbidity, function and recurrence.

References

1.
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2.
Monro A (1811) The morbid anatomy of the human gullet, stomach, and intestines. Archibald Constable & Co, Edinburgh: p 363 .
3.
Broden G, Dolk A, Holmstrom B. Recovery of the internal anal sphincter following rectopexy: a possible explanation for continence improvement. Int J Colorectal Dis. (1988);3(1):23–28. [PubMed: 3361220]
4.
Jurgeleit H C, Corman M L, Coller J A, Veidenheimer M C. Symposium: Procidentia of the rectum: teflon sling repair of rectal prolapse, Lahey Clinic experience. Dis Colon Rectum. (1975);18(6):464–467. [PubMed: 1181148]
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6.
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7.
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8.
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9.
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10.
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11.
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12.
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13.
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14.
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18.
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20.
Ramanujam P S, Venkatesh K S, Fietz M J. Perineal excision of rectal procidentia in elderly high-risk patients. A ten-year experience. Dis Colon Rectum. (1994);37(10):1027–1030. [PubMed: 7924710]
21.
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22.
Lechaux J P, Lechaux D, Perez M. Results of Delorme's procedure for rectal prolapse. Advantages of a modified technique. Dis Colon Rectum. (1995);38(3):301–307. [PubMed: 7882798]
23.
Oliver G C, Vachon D, Eisenstat T E, Rubin R J, Salvati E P. Delorme's procedure for complete rectal prolapse in severely debilitated patients. An analysis of 41 cases. Dis Colon Rectum. (1994);37(5):461–467. [PubMed: 8181408]
24.
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Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6929

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