Surgery for rectal prolapse Karen Nugent, Southampton Dukes’ Club 2013
What is rectal prolapse?• Full-Thickness rectal prolapse describes the entire rectum protruding through the anus• Mucosal prolapse describes only the rectal mucosa (not the entire wall) prolapsing• Internal intussusception where the rectum collapses but does not exit the anus.
Anatomical abnormality• Abnormally deep pouch of Douglas• Lax/atonic muscles of pelvic floor and anus• Weakness of sphincters (often with pudendal neuropathy)• Lack of normal fixation of rectum with mobile mesorectum and lax lateral ligaments
Cause of rectal prolapse• Rectal prolapse may be associated with the following conditions: – advanced age, – long term constipation, – long term straining during defecation, – receiving anal sex, – long term diarrhoea, – pregnancy and stresses of childbirth, – previous surgery,
How common?• Rectal prolapse is uncommon; however, the true incidence is unknown because of underreporting, especially in the elderly population.• Age – under 3 years old and after the 5th decade• 80-90% patients are women.• Associated features: 50% incontinence, 15%-65% constipation• The condition is often concurrent with pelvic floor descent and prolapse of other pelvic floor organs, such as the uterus or the bladder.• 35% of patients are nulliparous.
Demographics of rectal prolapse surgerypatients
Demographics of rectal prolapse surgerypatients
Investigations• Colonic imaging – to exclude neoplasm• Sigmoidoscopy - ? SRUS• Defecography• Anal rectal manometry is sometimes used to evaluate the anal sphincter muscles.• Marker study
Aims of treatment• Control prolapse and prevent recurrence• Restore normal bowel function – Restore continence – Prevent constipation/ impaired evacuationEITHER resection/plication of redundant bowelOR fixation of the rectum to the sacrum
Incarceration• An incarcerated rectal prolapse is rare. – Sugar!! – Emergency resection is required if the prolapse cannot be reduced and the viability of the bowel is in question.
Many ways to skin a cat!• 1959 – Charles Wells – ‘ I have traced in the literature between 30 and 50 operations for prolapse of the rectum and would like to add still one more’ – Over 100 procedures now described!
Delormes’ Operation• First described in 1900• A circumferential incision is made through the mucosa of the prolapsed rectum near the dentate line• Using electrocautery, the mucosa is stripped from the rectum to the apex of the prolapse and excised.• The denuded prolapsed muscle is then plicated with a suture and is reefed up like an accordion.• The transected edges of the mucosa are then sutured together.• Low morbidity- can be done under spinal
Altemeier• First used by Miles in 1933, Altemeier in 1971• Full-thickness circumferential incision is made in the prolapsed rectum at about 1-2 cm from the dentate line• The hernia sac is then entered, and the prolapse is delivered.• The mesentery of the prolapsed bowel is serially ligated until no further redundant bowel can be pulled down.• The bowel is transected and hand sewn to the distal anal canal or stapled using a circular stapler.• Before anastomosis, some surgeons plicate the levator ani muscles anteriorly, which may help improve continence
Perineal stapled prolapse (PSP) – stapledaltemeier• Pulling out the prolapse completely• At 3 and 9 o’clock, in lithotomy position — axially cutting it open with a linear stapler
PSP• Resection performed using a curved Contour Transtar stapler.• 32 patients (30 female:2 male)• Median age 80 years (range 26-93)• Median operation time was 30 minutes (range 15-65)• Median hospital stay was 5 days• 6 cartridges (range 4-12)
Functional outcome after PSP forexternal rectal prolapse• The median follow-up was 6 months (4-22)• Before surgery twelve (39%) patients complained of constipation, 10 (31%) reported a continuation of their symptoms after surgery. BMC Surgery 2010, 10:9
Perineal approach• Low morbidity• Possibly high recurrence rates• Avoids abdominal surgery and pelvic dissection• ‘cutting off an upturned sock – not fixing it’
Abdominal procedures• Suture rectopexy• Mesh rectopexy• Resection rectopexy• Lap vs Open
Posterior suture rectopexyFirst described by Cutait in 1959Mobilisation an upward fixation by fibrosis and suturingRecurrence 0-9%
Mobilisation alone may causeadequate fibrosis to treat prolapse• Suggested by John Goligher• 643 patients (1979-2001) – 46 mobilisation only – 130 resection -pexy – 467 pexy only• No significant difference in recurrence rates• 1,5 and 10 year recurrence rates were 1.06%, 6.61%, and 28.9 % Raftopoulos et al, DCR 2005 ;48:1200-6
Randomised controlled trial ofrectopexy vs no rectopexy• 252 patients in 41 centres randomised• Sigmoid resection was allowed in presence of constipation (more frequently in no rectopexy group)• No significant difference in complication rates• 5 year recurrence 8.6% vs 1.5% (p=0.003) Karas et al., DCR 2011:54:29
Posterior mesh rectopexy To create more fibrosis – Sponge used by Wells in 1959 Also a variety of absorbable and non absorbable meshes
Posterior mesh rectopexy• Low recurrence and low mortality• Pelvic sepsis – 2-16%• Haematoma should be avoided by draining pelvis (esp if considerable ooze)• Incontinence improved but constipation made worse
Resection rectopexy• Resection of redundant rectosigmoid• Straight course of left colon – more fixation• Relief of constipation
Lap vs Open• Simple procedure• Reduced pain• Reduced hospital stay• Studies show lap as effective as open – No difference in incontinence, constipation or recurrence Sajid et al, Colorectal Dis 2010:12:515-25
Long term results• 10 year period – 1994-2004 – 321 patients treated by 4 colorectal surgeons – 128 perineal procedures • 99 Delormes’ • 29 Altemeier – 193 abdominal procedures • 126 laparoscopic rectopexies • 46 open rectopexies • 21 resection rectopexies Byrne et al DCR 2008: 51:1597
Lap rectopexy method• Full circumferential mobilisation to pelvic floor• ‘lateral ligaments’ divided• Polypropylene mesh secured to sacrum and lateral rectum (with protacker)• Audit• Low numbers interviewed re functional results• Poor definition of recurrence
Long term results (lap rectopexy)• 17 patients thought they had a recurrence at median of 5 years of follow up• 5 confirmed full thickness recurrence (126) – 4%• 7 had banding for mucosal prolapse• Others had no evidence of FTRP• Incontinence scores improved - 6.6 to 3.4• Constipation scores no change – 4.2 to 4.3
Summary of results Recurrence•Delormes 0-38%•Altemeier 0-16%•Posterior suture rectopexy 0-9%•Mesh posterior rectopexy 0-6%•Resection rectopexy 0-5%•Post operative constipation in up to 50% of rectopexypatients
Why constipation associated withrectopexy? Full mobilisation of rectum Autonomic nerve injury Dysmotility and impaired evacuation
Lap ventral mesh rectopexy• Purpose of surgery for rectal prolapse to correct prolapse, protect or restore continence and avoid constipation• Correct middle compartment prolapse too• D’Hoore and Penninckx 2004• 42 patients with total rectal prolapse D’Hoore et al: BJS 2004:91:1500
Dissection from sacral promontoryavoiding nerves
Deep part of fold of Douglas retractedand incised
Polypropylene mesh suturedto anterior aspect of rectum and fixedto sacral promontory (Loosely)
By 2006• 109 patients (From 1995 – 2004)• Mean age 49.3 years• Hospital stay 5 days• Minor morbidity – 7%• 3 recurrences – detachment at sacral promontory• No mesh erosions D’Hoore and Penninckx Surg Endosc 2006:20:1919
Lap ventral mesh rectopexy • Systematic review in 2010 of 12 non randomised studies -728 patients • Recurrence of 3.4% • Improvement in incontinence of 45% • Improvement in constipation of 24%
Complications• Complications of 1.4 – 47% – 1 death from septicaemia from mesh infection – 1 mesh erosion of posterior vaginal wall – 2 mesh detachments – 3 deaths – MI, PE and CVA – 6 post – operative bleeds• Less constipation• Short follow up in some patients• Mixed reasons for VMR Samaranavake CB et al. Colorectal Dis 2009
Lap Ventral Mesh Rectopexy-Oxford results• 65 patients with external prolapse• 93% female• Median age 72 years (range 16-93)• Median follow up 19 months Boons et al Colorectal Dis 2010: 12:526-32
Lap VMR results• Median operating time 140 mins• Length of stay 2 days• 1 recurrence – delormes and 2 mucosal prolapse – banding• No mortality• 5 surgical re-interventions – 1 portsite haematoma and 4 port site hernias
Lap VMR -? Treats prolapse with low recurrenceand improves constipation without resection
Warning• In 2008, the FDA released a warning to healthcare professionals outlining complications linked to the use of surgical mesh in treating pelvic organ prolapse (and stress urinary incontinence). • To date, FDA has received almost 4000 reports of adverse events linked to the surgical mesh.• The agency issued a second warning July 13, 2011, as a result of a spike in reports of serious adverse events associated with mesh.
US Litigation• On July 13, 2011, the FDA announced that patients undergoing pelvic organ prolapse repair with a surgical mesh may be at a greater risk for mesh complications than women pursuing other surgical treatments.• Because the manufacturers of trans vaginal meshes failed to warn patients and doctors about this increased risk, women suffering mesh complications may be able to file a claim seeking compensation for medical bills, pain and suffering and other damages.
Incidence of complications with meshfor vaginal prolapse repair – systematic review1950-2010110 studies overall synthetic biological• Mesh erosion 10.3% 10.3% 10.1%• Wound granulation 7.8% 6.8% 9.1%• Dyspareunia 9.1% 8.9% 9.6%• Treatment – removal required in >50% Abed et al Int Urogynecol J 2011:22:789
Vaginal mesh contraction withpolypropylene meshes• Shown by ultrasound- progressive and linear relationship – 30% contraction at 3 years – 65% contraction at 6 years – 85% contraction at 8 years• Presents with – Pain – Dyspareunia – Erosion – Discharge Feiner and Maher: Obs and Gyne 2010:115:325
Erosion rates for gynaecologists 273 patients Erosion rates• Abdominal sacrocolpopexy 3.2%• Abdominal sacro colpo perineopexy 4.5%• Transvaginal 16%• Time to mesh erosion 6 weeks to 6 years – mean of 21 months Visco et al: Am J Ob Gyn 2001:184:297
Lap VMR – is it a time bomb?• Contraction• Erosion
Lap VMR – cure?• An excellent cure rate and improvement in incontinence and constipation for full thickness rectal prolapse• Good long term results and no reports of mesh erosion in colorectal literature
Lap VMR – or not?• Mesh may continue to shrink with time• Worrying and increasing numbers of vaginal erosions in gynaecological procedures• Erosion – difficult to treat
What procedure?• Role for perineal procedure in elderly unfit patients – Low morbidity and high recurrence• Role for rectopexy – preferably laparoscopic in patients fit for anaesthetic – Posterior suture rectopexy as good as posterior mesh (avoid taking the lateral ligaments) – Ventral mesh rectopexy adds a mesh but is superior if perineal descent and other organ prolapse, avoids new constipation – MESH!
Is perineal approach really safer?• 1469 patients identified from American College of Surgeons National Surgical Quality improvement data (2008-9)• Age• ASA class• Approach Fang et al DCR 2012:55:1167
Conclusion• Tailor the procedure to the patients fitness and anaesthetic risks• Tell the patient the risks vs the recurrence rates• VMR in women with any evidence of middle compartment prolapse – Mesh – Longer op time – Potential mesh compications– Remember 10% are men