Yosef Nasseri M.D. Yosef Nasseri M.D. Rectal Prolapse Cedars Sinai Medical Center Cedars Sinai Medical Center Medicine Resident Talk Medicine Resident Talk
Jun 03, 2015
Yosef Nasseri M.D.Yosef Nasseri M.D.
Rectal Prolapse
Cedars Sinai Medical CenterCedars Sinai Medical CenterMedicine Resident TalkMedicine Resident Talk
Introduction
♦ Rectal prolapse or procidentia:
● Full-thickness protrusion of the rectum through the anal sphincters
● A “falling down” of the rectum so that it’s out of the body
Introduction
♦ Internal prolapse or intussusception:● Occult rectoanal intussusception
● Prolapse does not protude from the anus
● Not always pathologic/symptomatic
● Occurs in 50% of defograms
♦ Rectal mucosal prolapse: ● Protusion of the rectoanal mucosa
Mucosal vs Full Rectal Prolapse
♦ To compare the quality of collagen in patients with hemorrhoidal disease versus normal controls
♦ To compare the quality of collagen between different genders and age groups
Mucosal vs Full Rectal Prolapse
Difference Between Rectal Prolapse and Hemorrhoids
Rectal Prolapse Hemorroids
Tissue Folds Circumferential Radial
Abnormality on Palpation
Double Rectal Wall
Hemorrhoidal Plexus
Resting and Squeeze Pressures
Decreased Normal
Difference Between Rectal Prolapse and Hemorrhoids
Pathophysiology
♦ Result from● Constipation (component of colonic dysmotility)● Weakening/malfunctioning of pelvic floor/sphincters● Anismus – spastic pelvic floor● Pudendal neuropathy (obstetric injuries, aging)● Sphincter dysfunction (trauma, aging)
♦ Chronic straining – progression of disease● Intussusception -> prolapse● OR rectocoele w/ or w/out rectal ulcer
Pathophysiology♦ Rectum passes through opening in pelvic floor funnel
♦ With BMs, intussusception occurs much like what happened with hiatal hernia
♦ Lateral & rectosigmoid attachments relax
♦ Mesorectum lengthens
♦ Anal sphincters stretch
♦ Rectal prolapse
Method
Pathophysiology
♦ Associated pelvic anatomic abnormalities
● Deep anterior cul de sac
● Redundant sigmoid colon
● Patulous anal sphincter
● Loss of posterior rectal fixation
Clinical Features ♦ Mucus Discharge
♦ Rectal Bleeding
♦ Soilage
♦ Feeling of incomplete evacuation
♦ Diarrhea
♦ Itching
Clinical Features ♦ Extreme of age
♦ Children: first three years (male=female)● Cystic fibrosis, malnutrition, diarrhea, severe cough,
parasites
♦ Adults: majority are eldery female
● Females >50 – 6 times more likely than males
● 2/3 are multiparous
● Mental illness (depression, autism)
● Neurologic disorder
● Connective tissue disorder
● Constipation and straining
Clinical Features ♦ Constipation is associated with prolapse in 30%-70% of pts
♦ Chronic straining, sensation of anorectal blockage, need of digital evacation
♦ 60% have coexisting incontinence
● Stretching of anal sphincters
● Impaired rectal compliance
♦ 20-35% have associated urinary incontinence
Take Home Message
♦ USUALLY BOTH A FUNCTIONAL AND ANATOMIC COMPONENT TO THIS PROBLEM
♦ IMPORTANT WHEN CHOOSING SURGERY AND POST-OP TREATMENT ● Surgical intervention may worsen either the
incontinence or constipation ● Post-op biofeedback therapy often needed
Evaluation
♦ Ask patient to produce the prolapse
♦ If not obvious
● straining in sitting position (toilet)
● phosphate enema or glycerine suppositories (children) to induce strain
♦ Look for associate vaginal prolapse (15-30%)
Evaluation♦ Concentric rings and grooves
♦ Perianal skin excoriation and maceration
♦ Chronic prolapse● Inflamed, edematous and irregular surface ● Biopsies to rule out neoplasia
♦ Digital examination● Sphincter pressures
♦ Colonoscopy or barium enema ● Exclude tumor● Biopsy of ulcers and mass lesions
Evaluation♦ Defecography ● Rectocele
● Internal intussusception
♦ Anal manometry can help assess sphincters● Longstanding prolapse may damage internal sphincter
♦ EMG for patients with history of severe straining
♦ Colonic transit times with severe constipation● May need colon resection
Nonoperative management
♦ Treat constipation● Fiber supplements
● Stool softeners
♦ Reduce incarcerated rectal prolapse● Table sugar
Surgical Treatment
♦ Mainstay in treatment of rectal prolapse
♦ Over 100 procedures
♦ Perineal procedures● Resection, reefing, and encirclement
♦ Abdominal procedures● Fixation, colon resection or combination of both
Choosing Type of Surgery/ Perineal
♦ High-risk or eldery patients
♦ Advantages● Low morbidity and pain
● Low mortality
♦ Disadvantages● Higher recurrence rate
● Risks coloanal leak
Choosing Type of Surgery/ Abdominal
♦ Overall better results than perineal
approaches
♦ Full mobilization of the rectum, sacral fixation
with or without resection
♦ Younger patients
♦ Most common procedures● Rectopexy
● Resection and rectopexy
Choosing Type of Surgery♦ Abdominal
● Recurrence low (<10%)
● ↑ constipation 50%
● Higher M & M esp.
with anastomosis
● Mesh placement – stricture, migration, erosion, infection
♦ Perineal● Recurrence (20%)
● Constipation rate unchanged
● Persistent incontinence worse rate due to removal of rectal resevoir
● Correction of associated abnormalities (rectoceole, sphincter)
● No pelvic dissection – preserves sexual function
Perineal Procedures
♦ Perineal Proctosigmoidectomy – Altmeier
♦ Mucosal Sleeve Resection - Delorme
♦ Anal Encirclement - Thiersch Wire Technique
♦ Perineal suspension/fixation - Wyatt
Altmeier Procedure
Delorme Procedure
Delorme Procedure
Delorme Procedure
Thiersch Procedure
Perineal Procedures - Advocates
♦ Pts suffer mainly from incontinence, constipation and decreased quality of life
♦ Pts are not mainly threatened from recurrence
♦ Surgery should be verified in priority to its effect on post op QOL rather than recurrence
Abdominal Procedures
♦ Anterior rectopexy or Ripstein procedure ● Anterior wrapping of the rectum and fixation to sacrum
♦ Posterior rectopexy - Wells procedure
● Synthetic mesh
● Sutures alone
♦ Sigmoid colectomy with sutured rectopexy ● Low recurrence
● Low morbidity
● Improves constipation
Ripstein Procedure
Ripstein Procedure
Ivalon Sponge
Laparoscopic Rectopexy
♦ Largely replacing open abdominal procedures
♦ Ease of performing rectopexy and colon resection simultaneously with shorter hospital stay
♦ Morbidity and mortality no different than open controls
♦ Recurrence rate lower but not statistically significant
Rectopexy +/- Resection
♦ Rectopexy with resection - Multiple papers
● Improvement in continence and constipation
● Mortality – 0-6.7%
● Recurrence – 0-5%
♦ Rectopexy without resection - Wilson et. Al
● 9% recurrence at 48 month f/u
● 17% severe constipation managed by laxatives
Laparoscopic Rectopexy
♦ 152 pts over 16 yrs
♦ Conversion rate 0.7%
♦ Mean OR time – 204 mins
♦ Mean follow up – 47 months
♦ Improvement or no constipation – 81%
♦ Recurrence rate – 11%
Laubert et al, Surg Endoscopy 2010
Laparoscopic vs. Open Rectopexy
♦ 40 patients
♦ Randomized to laparoscopic or open group
♦ Significant differences in favor of laparoscopy in narcotic requirement, pain and mobility scores
♦ Respiratory morbidity greater in open group
Solomon et al, BJS, 2002
Laparoscopic vs. Open Rectopexy
♦ 126 laparoscopic rectopexy vs 46 open rectopexy vs
21 resection rectopexy
♦ Median follow up – 5 yrs
♦ No significant difference in recurrence between
groups (4%)
Byrne et al, DCR, 2008
Laparoscopic vs. Open Rectopexy
♦ Meta analysis
♦ 12 studies of 688 pts
♦ Laparoscopy
● Longer operation
● Decrease LOS
♦ No difference in constipation, incontinence, M&M
♦ Recurrence not recorded
Sajid et al, DCR, 2010
Recurrence
♦ Can happen after either perineal or abdominal
procedure
● Overall 15% recurrence rate (range is 0-60%)
● Abdominal operations – up to 10%
● Perineal operations – up to 20%
Recurrence
♦ 2 types of recurrence ● Mucosal
● Full thickness
♦ Early recurrence ● Occurs within first year
● Likely the result of a specific technical failure
♦ Non-early recurrence ● Generally occurs 18-24 months postoperatively
Recurrence - Etiology♦ Surgical factors
● Inadequate mobilization of rectum
● Inadequate fixation of the rectum to the sacrum
● Incomplete resection of a redundant rectosigmoid
♦ Nonsurgical factors: ● Vigorous physical activity or childbirth – disruption of pexy
● Continued constipation with persistent straining
♦ Pathophysiologic factors: ● Disordered defecation
● Intestinal dysmotility
Recurrence - Literature
♦ Meta-analysis
♦ 264 pts in 8 trials
♦ Included both abdominal and perineal operations
♦ Extent of rectal dissection is the single most important factor in decreasing recurrence (divide the lateral ligaments)
♦ No difference between mesh or suture alone
Bachoo, Cochrane Database Sys Rev 2000
Conclusions
♦ Consider surgery when conservative therapy fails
♦ Careful pt selection is crucial to satisfactory outcome
♦ Tailor surgery to the specific pt
♦ Laparoscopic rectopexy allows for quicker recovery
and shorter LOS but similar recurrence
♦ Regardless of material used, correct suture and tack
placements are crucial
♦ If severely constipated, perform sigmoidectomy
♦ Pts care as much about continence and constipation