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