Treatment of rectal prolapse by sphincteric support using silastic rods

Rectal Prolapse Surgery: Balancing Effectiveness and Safety in Abdominal and Perineal Approaches

The event in which the entire thickness of the rectum protrudes through the anal canal is called rectal prolapse. This ailment is common in the elderly population and especially in females. It causes some disastrous symptoms, including incontinence to feces and flatus, constipation, and discomfort, because of the weakness in the anorectal junction, making it mandatory for surgical correction. Over time, several surgical techniques have been developed; these are broadly classified into two categories: abdominal and perineal techniques. However, the best approach for surgery that minimizes recurrence while maximizing patient quality of life is still up for debate. A comprehensive review was conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; a systematic search of the PubMed Database was performed to identify studies published between 2000 and 2024 with the keywords ((Rectal Prolapse) AND ("Perineal" OR "Laparotomy")). The inclusion criteria were focused on studies comparing the outcomes between surgical approaches at the abdominal and perineal locations, particularly on the recurrence rate, postoperative complications, and functional outcomes. In total, 21 studies were included in the review: these ranged from retrospective analysis and prospective studies to a multicentric randomized trial. In this review, abdominal approaches, particularly in the form of laparoscopic rectopexy, consistently demonstrated improved results compared to perineal techniques, with a much lower recurrence rate. The rates of mortality and morbidity were also remarkably lower in laparoscopic operations, which were advocated for suitable patients. However, perineal approaches, while still producing higher rates of recurrence, are a valuable alternative for elderly and high-risk patients due to their being relatively less invasive. Laparoscopic rectopexy can be considered a better surgical method for rectal prolapse, as it has a lower recurrence rate and better functional outcomes. In contrast, perineal approaches will have their place in the management of rectal prolapse, given patient selection for patients at high risk with regard to surgery. Future research should be directed toward multicenter trials with long-term outcomes in order further to fine-tune surgery strategy and criteria for patient selection.

Bio-Thiersch as an Adjunct to Perineal Proctectomy Reduces Rates of Recurrent Rectal Prolapse

BACKGROUND

The rates of recurrent prolapse after perineal proctectomy vary widely in the literature, with incidences ranging between 0% and 50%. The Thiersch procedure, first described in 1891 for the treatment of rectal prolapse, involves encircling the anus with a foreign material with the goal of confining the prolapsing rectum above the anus. The Bio-Thiersch procedure uses biological mesh for anal encirclement and can be used as an adjunct to perineal proctectomy for rectal prolapse to reduce recurrence.

OBJECTIVE

The aim of this study was to evaluate the Bio-Thiersch procedure as an adjunct to perineal proctectomy and its impact on recurrence compared with perineal proctectomy alone.

DESIGN

A retrospective review of consecutive patients undergoing perineal proctectomy with and without Bio-Thiersch was performed.

SETTINGS

Procedures took place in the Division of Colon and Rectal Surgery at a tertiary academic teaching hospital.

PATIENTS

Patients who had undergone perineal proctectomy and those who received perineal proctectomy with Bio-Thiersch were evaluated and compared.

INTERVENTIONS

All of the patients with rectal prolapse received perineal proctectomy with levatorplasty, and a proportion of those patients had a Bio-Thiersch placed as an adjunct.

MAIN OUTCOME MEASURES

The incidence of recurrent rectal prolapse after perineal proctectomy alone or perineal proctectomy with Bio-Thiersch was documented.

RESULTS

Sixty-two patients underwent perineal proctectomy (8 had a previous prolapse procedure), and 25 patients underwent perineal proctectomy with Bio-Thiersch (12 had a previous prolapse procedure). Patients who received perineal proctectomy with Bio-Thiersch had a lower rate of recurrent rectal prolapse (p < 0.05) despite a higher proportion of them having had a previous prolapse procedure (p < 0.01). Perineal proctectomy with Bio-Thiersch had a lower recurrence over time versus perineal proctectomy alone (p < 0.05).

LIMITATIONS

This study was limited by nature of being a retrospective review.

CONCLUSIONS

Bio-Thiersch as an adjunct to perineal proctectomy may reduce the risk for recurrent rectal prolapse and can be particularly effective in patients with a history of previous failed prolapse procedures.

Clinical utility of sclerotherapy with a new agent for treatment of rectal prolapse in patients with risks

BACKGROUND

Perineal approaches are widely applied for the treatment of rectal prolapse. Recently, less-invasive treatments such as sclerotherapy using aluminum potassium sulfate/tannic acid (ALTA) have been introduced for internal hemorrhoids. Herein, we report the results of ALTA injection for the treatment of rectal prolapse in high-risk patients.

METHODS

Between January 2009 and March 2011, we performed ALTA injection sclerosing therapy in 12 female patients with high risk for preoperative complications. Using the perineal approach, 0.5 to 1 mL of ALTA was injected into the submucosa at 30 to 60 different sites.

RESULTS

All patients were successfully treated without any operative or postoperative morbidity. Average operation time took 35±7 (mean±SD) minutes, and average volume of ALTA injected was 39±6 mL per patient. Neither complaints of bleeding nor findings of anal stenosis were noted. A slight degree of recurrence of prolapse developed in a patient after 8 months. The patient required an additional injection to be cured.

CONCLUSIONS

ALTA injection could be administered for the treatment of rectal prolapse without any pain or complication and would be useful even for patients with risks due to preoperative complications and/or medical history.

Surgical treatment of rectal prolapse

Rectal prolapse is defined as a protrusion of the rectum beyond the anus. Although rectal prolapse was recognized as early as 1500 BC, the optimal surgical procedure is still debated. The varied operative procedures available for treating rectal prolapsed can be confusing. The aim of treatment is to control the prolapse, restore continence, and prevent constipation or impaired evacuation. In elderly and high-risk patients, perineal approaches, such as Delorme's operation and Altemeier's operation, have been preferred, although the incidence of recurrence and the rate of persistent incontinence seem to be high when compared with transabdominal procedures. Abdominal operations involve dissection and fixation of the rectum and may include a rectosigmoid resection. From the late twentieth century, the laparoscopic procedure has been applied to the treatment of rectal prolapse. Current laparoscopic surgical techniques include suture rectopexy, stapled rectopexy, posterior mesh rectopexy with artificial material, and resection of the sigmoid colon with colorectal anastomosis with or without rectopexy. The choice of surgery depends on the status of the patient and the surgeon's preference.

Der Rektumprolaps des Erwachsenen

The etiology of rectal prolapse is unclear. Diagnosis is easy by local inspection. The ideal surgery would repair the prolapse, correct any functional problems such as incontinence or constipation, be minimally invasive and cost-effective, and result in minimal morbidity and recurrence. The best surgical repair remains controversial-whether by the transanal/perineal or abdominal approach-with or without resection and rectopexy. There are no prospective-randomized studies that convincingly answer the numerous questions. The best possible option today seems to be the abdominal/laparoscopic method with a resection rectopexy according to Frykman and Goldberg.

Functional problems in adult rectal prolapse and controversies in surgical treatment

BACKGROUND

Rectal prolapse is a condition that has fascinated surgeons for a long time. To date, no single ideal surgical treatment has been identified. The aetiology of rectal prolapse remains highly controversial, but it is recognized that associated functional problems, such as incontinence and constipation, are common. The pathophysiology, and controversies surrounding continence and constipation, remain topics of debate.

METHOD

All relevant papers derived from Medline and manual searching on rectal prolapse and associated functional problems were reviewed.

RESULTS AND CONCLUSION

The surgical management of rectal prolapse has evolved from historical encirclement procedures to current minimally invasive ones. Successful management must include adequate attention to the associated functional problems in order to eradicate the basic abnormality.

Anal encirclement with polypropylene mesh for rectal prolapse and incontinence

Seventeen selected patients (mean age, 74 years)--14 with rectal prolapse and 3 with persisting anal incontinence after previous operations--underwent high anal encirclement with polypropylene mesh. There was no operative mortality. Prolapse recurred in 2 (15 percent) of the 13 patients followed up for 6 months or more (mean, 3.5 years). Three (27 percent) of the 11 patients with associated anal incontinence improved functionally, as did the three operated on for persisting incontinence, but only one patient regained normal continence. No breakage, cutting out, or infection related to the mesh was observed. Because of the risk of fecal impaction encountered in three of our patients, the procedure is not advocated for severely constipated patients. Despite the somewhat disappointing results regarding restoration of continence, we find this method useful in patients with rectal prolapse who are unfit for more extensive surgery, in controlling the prolapse to an acceptable degree.

Perineal excision of the rectum for prolapse in the elderly

A perineal operation is described for the treatment of rectal prolapse. The surgery improves functional outcome by correcting the anatomical anomalies associated with the condition. In 17 elderly women, there was one perioperative death and one recurrence. At a median follow-up of 24 months, 13 patients were able to control solid stool and three were profoundly incontinent. The operation may be an alternative to the more invasive abdominal procedures for the treatment of the majority of patients with prolapse.

Rectal prolapse. Surgical techniques

The varied operative procedures available for the treatment of rectal prolapse can be confusing. Most of the maneuvers are relatively esoteric and can be performed successfully only by the few surgeons who have developed the specialized techniques. It is recommended, therefore, that the surgeon who is less experienced with rectal prolapse adopt one of the standard operations. A rectopexy or suspension procedure without resection can be performed safely with good results, low morbidity, and a low mortality rate. Anterior resection with or without sacral fixation, an operation familiar to most surgeons, also offers an excellent cure rate. The Thiersch-type approach should probably be reserved for those patients who cannot tolerate laparotomy. The material chosen should be one of the commercially available synthetic products; wire should not be used. The Silastic-impregnated Dacron prosthesis for this operation has some potential benefit, especially for the incontinent patient. Results of further studies are awaited.

Silicone elastomer sling for fecal incontinence in dogs

Fecal incontinence was created by bilateral pudendal neurectomy in 12 dogs. In six dogs, the fecal incontinence was treated by implantation of a polyester-impregnated silicone elastomer sling to form an artificial external anal sphincter. Six dogs underwent the same operative procedure without the implant to serve as controls. Five dogs regained total continence and one dog regained partial continence after implantation of the sling. Four control dogs remained incontinent and two control dogs regained partial continence. The difference between the dogs with slings and the controls was statistically significant (P less than 0.01). The only complication was infection in one dog, which was treated successfully. Histologic reaction to the implant was confined to a zone of fibrosis 1 to 3 mm surrounding the implant. The sling was well tolerated clinically and appeared to offer a successful method for correction of fecal incontinence in dogs.

Perineal excision of rectal prolapse with posterior levator ani repair in elderly high-risk patients

Perineal excision of rectal prolapse with simultaneous posterior levator ani repair was used to treat 41 elderly patients with rectal procidentia. The majority of the patients had significant associated risk factors. This procedure was performed with minimal morbidity and no mortality. A significant improvement in anal continence was seen in 78 percent of patients. The recurrence rate of rectal prolapse was 4.8 percent.

Treatment of rectal prolapse by Delorme's operation

Rectopexy in the sacral hollow or to the promontory with synthetic material is the most efficient method of reducing and fixing a complete rectal prolapse. However, this distressing condition occurs frequently in elderly patients, often with high operative risk. In these some surgeons have advocated a perineal approach. Eighteen female patients (mean age 74 years) with complete rectal prolapse have been treated by a modified Delorme's procedure which involves a mucosal stripping of the prolapse and longitudinal plication of the muscular wall of the rectum. There was no postoperative mortality or morbidity. After a mean follow-up of 18 months, two complete recurrences occurred. These were treated by the same technique with a good result at 3 years. One other patient presented a partial and intermittent recurrence. Incontinence has improved in four patients and was not made worse in the others. Our results and those previously published show that this procedure is safe in elderly high risk patients considered too unfit for transabdominal surgery.

Postanal repair and intersphincteric Ivalon sponge rectopexy for the treatment of rectal prolapse

Twenty-four consecutive patients (mean age: 74 years) with complete rectal prolapse, fifteen of whom were incontinent of solid stool, have been treated by postanal repair and intersphincteric Ivalon sponge rectopexy. There was no operative mortality, or serious morbidity. There was one recurrence of complete prolapse which occurred 14 days after operation. The other 23 patients have been followed for up to 4 years. All patients who were incontinent of solid stool pre-operatively have been rendered continent. This type of operation may be the treatment of choice in the elderly, where an abdominal procedure is considered unwise and in cases of rectal prolapse associated with faecal incontinence.

Late results of silicone rubber perianal suture for rectal prolapse

Twenty-one patients were reviewed five to 12 years after silicone rubber perianal suture for rectal prolapse. Sixteen patients (76 percent) were continent with control of prolapse and two patients (9 percent) suffered only from occasional prolapse or incontinence. Rebanding for silicone cutout or fracture was required in four patients and a second rebanding operation was needed in two. Silicone rubber perianal suture for rectal prolapse stands the test of time and might be recommended for more widespread use in younger patients.