Evedenced Based Rectal Prolapse

8/18/2019 Evedenced Based Rectal Prolapse

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Evidence Based approach to RectalProlapse

Dr T V Aditya Chowdary


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Complete rectal prolapse (procedentia) –

Circumferential full thicness descent of the

rectum outside the anus

Pathophysiology of rectal prolapse - DISTALINTUSSUSCEPTIN of the rect!m

Associated "actors

!ea levator ani and anal sphincter muscles"

A redundant rectosi#moid colon

A deep cul$de$sac

%oss of &'ation of the rectum to the sacrum


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Complete rectal prolapse (procedentia) –

Circumferential full thicness descent of the

rectum outside the anus

Pathophysiology of rectal prolapse - DISTALINTUSSUSCEPTIN of the rect!m

Associated Conditions

(ental llness *fourfold ris)

connective tissue disorders

pelvic outlet o+struction

pelvic ,oor la'ity spina +i&da

multiple sclerosis

cystic &+rosis

anore'ia and +ulimia nervosa

e'cess strainin#

Clinical "eat!res(ass PRBleedin#Constipation – -. /

Diarrhea $$ 01 /ncontinence – .2 /


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A#dominal Approach

Rectope'y

Ripstein

!ells

Resection

Resection Rectope'y

3uywan

Perineal Approach

Perineal

Proctosi#moidectomy $

Altaemeier

Anorectal (ucosectomy

!ith (uscular Plication$

Delorme

Anal Encirclement $

Therisch

(ana#ement


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Preoperative worup

Document +aseline anorectal anatomy and function prior to repairAnal manometry

4ltrasono#raphy

Pudendal nerve terminal motor latency

Dvorin %5" Chan C%" 6nowles C7" et al8 Anal sphincter morpholo#y in patients with full$thicness rectal prolapse9 Dis ColonRectum :.80;


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C@TR@VER5E5 54RCA%APPR@AC7

either the type of procedure *intra$a+dominal

versus perineal) nor the approach *open versus

minimally invasive) has +een identi&ed as optimal

• 5uture or mesh rectope'y

• Anterior or posterior mesh wrap

• Rectope'y alone or with si#moid resection

• E'tent of pelvic dissection and division of the lateral li#aments

• Anterior versus posterior mo+iliation

• Perineal approach in youn# men to spare ris of pelvic nerve

inury


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A+dominal Vs Perineal

Recurrence Rates

A+dominal 2/ to 1 / " Perineal 02/ – 01/

The perineal procedures are #enerally reserved for the most elderly

and frail" particularly those who are not candidates for either anopen or laparoscopic approach

• Clar CE" upiter DC" Thomas 5" Papaconstantinou9 Rectal Prolapse in the Elderly8 Trends in 5ur#ical(ana#ement and @utcomes from the American Colle#e of 5ur#eons ational 5ur#ical Fualitymprovement Pro#ram Data+ase9 AC5 =20=G=018.2;9

• 5ur#ical mana#ement of rectal prolapse9 (adi+a TE" Bai# (6" !e'ner 5D Arch 5ur#9 =221

anG0:2*0)8-H$.H

• Comor+id illnesses that preclude an intra$a+dominal procedure

• 3ailed previous intra$a+dominal rectal procidentia repair procedure

• Prior pelvic sur#ery

• Prior pelvic radiation therapy

• Ioun# males" in order to minimie the ris of erectile dysfunction9

There is little" if any" ris of dama#e to the hypo#astric nerves with

the perineal procedures9(ahmoud 5A" @mar !" A+del$Elah 6" 3arid (9 DelormeJs Procedure for 3ull$Thicness Rectal ProlapseGDoes it Alter Anorectal 3unction9 ndian 5ur# =20=G .:8H


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5uture Vs (esh Rectope'y

A single centre comparati$e st!dy of laparoscopic meshrectope%y $ers!s s!t!re rectope%y – & ' Sahoo A 6

Thimme#owda" (ano 5 owda (inim Access 5ur#9 =20: an$(arG 02*0)8 0


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Anterior vs PosteriorRectope'y

• Recurrence rates for anterior and posteriorrectope'y are similar9

• Rate of stricture and postoperative constipation

$ posterior < anterior rectopexy

01/ e'perience new onset constipation and 12/ have worsenin#

of constipation with rectopexy alone

"!nctional res!lts of operati$e treatment of rectal prolapse o$er an ,,-yearperiod emphasis on transa#dominal approach+Aitola PT0" 7iltunen 6(" (atiainen (9 Dis Colon Rectum9 0;;; (ayG:=*1)8-11$-29


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Resection Alone

Anterior resection alone – associated with hi#herrecurrence rates and si#ni&cant operative andpostoperative mor+idity

Recurrence rate ;/

Deterioration of continence has +een reported in 02–

=2/

Schlin.ert R T" Beart R ! r" !olK B " Pem+erton 79

Anterior resection for complete rectal prolapse9 Dis Colon

Rectum 0;


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Resection with sacral &'ation

Advanta#e of removin# e'cess +owel andrestorin# the normal rectal an#ulation9

This approach improves symptoms of +othincontinence and constipation9

&ado/ RD" !illiams " !on# !D" et al Long-termf!nctional res!lts of colon resection and rectope%y foro$ert rectal prolapse9 Am J Gastroenterol


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%ateral stal (o+iliations

Division of the lateral stalls will allow for +etter

rectal mo+iliation and &'ation and prevent

recurrence +ut at a cost of worsenin#constipation

Spea.man CT" (adden (V" icholls R" et al Lateralligament di$ision d!ring rectope%y ca!ses constipation#!t pre$ents rec!rrence 'es!lts of a prospecti$e

randomi0ed st!dy+ Br J Surg .


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%ap Vs @pen

(inimally$invasive *e#" laparoscopic" laparoscopic$

assisted" or ro+otic$assisted) colon and rectal procedures

have the advanta#es of reduced postoperative pain"

early return of +owel function" and shortened len#th of

hospital stay

()occasanta ,1123 Solomon 45546

• %ap L @pen

•

Better 3unctional results short term


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Delo'es trial st!dy protocol for arandomi0ed trial comparing t*o standardi0eds!rgical approaches in rectal prolapse -

Delorme7s proced!re $ers!s resectionrectope%y

=20= Au# =;G0H80119 doi802900

Evedenced Based Rectal Prolapse

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