Long-term results after Delorme procedure for rectal prolapse

coloproctology - The Delorme procedure is a perineal approach for the treatment of rectal prolapses, which is recommended for older patients with severe comorbidities. The aim of this...     

The Altemeier repair: Outpatient treatment of rectal prolapse

PURPOSE: Rectal prolapse typically occurs in elderly patients, who are often poor surgical candidates because of the presence of multiple comorbidities. Abdominal approaches to procidentia have low recurrence rates but are associated with higher rates of morbidity and mortality. Perineal rectosigmoidectomy (Altemeier repair) is a safe and effective approach to the treatment of rectal prolapse and can be done as an outpatient procedure. In this article, the results of a series of 63 consecutive Altemeier repairs are presented. METHODS: Between February 1993 and December 1999, 63 patients (61 females) underwent Altemeier repair of rectal prolapse. The mean patient age was 79 years. Preoperative, intraoperative, and postoperative data were collected and analyzed for all patients. RESULTS: Median follow-up was 20.8 months. Seventy percent of patients were given a regional or local anesthetic. The average resected specimen length was 11.6 cm, and 83 percent of anastomoses were stapled. Sixty-two percent of patients were discharged home on the day of surgery, and 80 percent were home within 24 hours. Complications occurred in 10 percent of patients, but there was no perioperative mortality. There was a 6.4 percent recurrence rate, and all recurrences were successfully treated with repeat Altemeier repair. All 63 patients had complete objective resolution of prolapse, and 87 percent had subjective improvement after repair. CONCLUSIONS: Altemeier repair of rectal prolapse is safe, produces minimal discomfort, and does not require a general anesthetic. It is ideally suited to be done on an outpatient basis, as was done in the majority of patients in our series. The recurrence rate is slightly higher than with abdominal resections, but morbidity and cost are lower, and repeat perineal resections are easily and safely performed.     

An emergency Altemeier procedure for necrosis of full-thickness rectal prolapse

Techniques in Coloproctology -     

Experience with the one-stage perineal repair of rectal prolapse

Our experience with 27 patients undergoing 33 Altemeier procedures for repair of rectal prolapse is presented. The overall recurrence rate during a 1- to 17-year follow-up period is 35 per cent (per patients) or 50 per cent (per operations). There was no mortality and only minimal morbidity, although we were dealing with an elderly group of patients (average age 61 years) with many associated diseases (2.8 diseases per patient). Of 13 patients with successful anatomic repair, ten described it as a success, one developed an anal stricture, and two patients claimed only partial success, despite a perfect anatomic repair, due to lack of improved continence. Our results with the Altemeier procedure for the repair of rectal prolapse are unsatisfactory. However, as the procedure is well tolerated by elderly and sick patients, it should be reserved for those.     

Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy

The results and complications of perineal rectosigmoidectomy for complete rectal prolapse in 114 patients have been reviewed. Most patients were elderly and high risk by virtue of other concurrent medical conditions. Fourteen patients (12 percent) developed significant postoperative complications. Hospital stay was short (median, four days). Ten patients were lost to follow-up. The remaining 104 patients were followed for 3 to 90 months. Eleven patients (10 percent) developed recurrent fullthickness rectal prolapse; six of them underwent repeat perineal rectosigmoidectomy. Sixty-seven patients had fecal incontinence prior to surgery. Eleven patients underwent concomitant levatoroplasty; 10 of them either improved or regained full continence of feces postoperatively. Twenty-six of the 56 patients who underwent perineal rectosigmoidectomy alone improved or regained full continence. Rectal prolapse can be successfully treated by perineal rectosigmoidectomy in elderly, highrisk patients with minimal morbidity. Levatoroplasty dramatically improves fecal incontinence occurring in association with rectal prolapse.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Laparoscopic resection rectopexy versus laparoscopic ventral rectopexy for complete rectal prolapse

Background

Laparoscopic resection rectopexy (LRR) and laparoscopic ventral rectopexy (LVR) are favored for the treatment for rectal prolapse (RP) in the USA and Europe, respectively. This study aims to compare these two surgical techniques.

Methods

All patients who underwent LRR because of RP between January 2000 and January 2012 at Cleveland Clinic Florida (Weston, FL, USA) were identified, and all relevant characteristics were entered in a database. This same analysis was also conducted for all patients who underwent LVR in the Meander Medical Center (Amersfoort, the Netherlands) between January 2004 and January 2012. These two cohorts were retrospectively compared with regard to complications, functional results and recurrence.

Results

Twenty-eight patients (all female, mean age 50.1 years) were included in the LRR cohort at a mean follow-up of 57 (range 2–140; standard deviation (SD) ± 41.2) months. The LVR group consisted of 40 patients (36 females and 4 males) with a mean age of 67.0 years and a mean follow-up of 42 (range 2–82; SD ± 23.8) months. A significant reduction in constipation was observed in both cohorts after surgery: 57 versus 21 % after LRR and 55 versus 23 % after LVR (both P < 0.05). The incidence of incontinence also significantly decreased in both groups: 15 % after LVR (55 % before surgery) and 4 % after LRR (61 % before surgery). Direct comparison of these two techniques showed a trend to significance (P = 0.09). Significantly, more complications occurred after LRR (n = 9: 1 major, 8 minor) then after LVR (n = 3: 2 major, 1 minor) (P < 0.05).

Conclusions

Both LVR and LRR are effective for the treatment for RP. Although both techniques offer significant improvements in functional symptoms, continence may be better after LRR. However, LRR also had a higher complication rate then did LVR.     

Laparoscopic rectovaginopexy for rectal prolapse

Background Open rectovaginopexy is an effective procedure for the treatment of both rectal prolapse and anterior rectocele. This study investigates our results of laparoscopic rectovaginopexy (LRVP). Methods A consecutive series of 14 patients (median age, 73 years; range 24–92) with rectal prolapse was planned for LRVP. Pre-, per- and postoperative parameters were recorded. Followup was performed at the outpatients’ clinic. Results The median length of hospital stay was 6 days (range, 3–14). There was one fatal cerebrovascular accident 14 days postoperatively; this patient was excluded from further analysis. Median follow-up was 7 months (range, 0.75–38). During follow-up, 11 of 13 patients (85%) experienced resolution or major improvement of their symptoms. Anal incontinence was diminished in 9 of 13 cases (69%). Constipation improved in 2 of 3 patients (66%). These three patients experienced a combination of both anal incontinence and costipation, preoperatively. Recurrence occurred in 2 patients (15%). Two others had a minor residual mucosal prolapse. No patients reported symptoms suggestive of operation-induced constipation or dyspareunia. Conclusions LRVP is feasible, and seems to be an effective procedure for rectal prolapse. No operationinduced constipation was observed in this series. Taking into account the age and co-morbidities of these patients, morbidity and mortality may be considered acceptable. An erratum to this article is available at .     

Laparoscopic-assisted resection-rectopexy for rectal prolapse

PURPOSE: Objectives of this study were to describe the technique of laparoscopic-assisted resection rectopexy and audit the clinical outcomes, including review of functional results. METHODS: Data were prospectively collected for duration of operation, time to passage of flatus and feces postoperatively, hospital stay, morbidity, and mortality. Follow-up was performed by an independent assessor using a standardized questionnaire. Patients were also assessed by clinical review or telephone interview. RESULTS: During a four-year period, 34 patients underwent laparoscopic repair for rectal prolapse, of which 30 patients underwent laparoscopic-assisted resection rectopexy. Median duration of the operations was 185 minutes, median time for passage of flatus was two days postoperatively, and median length of hospital stay was five days. Morbidity was 13 percent and mortality rate was 3 percent. Comparison between the first ten patients who underwent laparoscopic-assisted resection rectopexy and the last ten revealed a significant reduction in both median duration of operating time (224vs. 163 minutes;P<0.005) and length of stay (6vs. 4 days;P<0.015). Follow-up study conducted at a median time of 18 months revealed that most patients (92 percent) felt that the operation had improved their symptoms, that incontinence was improved in 14 of 20 patients with impaired continence (70 percent), and that constipation was improved in 64 percent. Symptoms of incomplete emptying and the need to strain at stool were both improved in 62 and 59 percent of patients, respectively. No full-thickness recurrences have occurred, but two patients have had mucosal prolapse detected (7 percent) and treated. CONCLUSION: Laparoscopic-assisted resection rectopexy is feasible and safe, with acceptable recurrence rates and functional results compared with the open procedure in the surgical literature. There is rapid return of intestinal function associated with an early discharge from hospital.Read at the meeting of The Royal Australasian College of Surgeons, Brisbane, Australia, May 11 to 15, 1997.     

Abdominal rectopexy for rectal prolapse

PURPOSE: The aim of this study was to investigate the influence of surgical technique on functional and manovolumetric results in patients treated with Marlex^® mesh abdominal rectopexy. METHODS: The lateral ligaments were completely divided (the Wells procedure) in 16 patients and preserved (the Ripstein procedure) in 16 patients. Clinical and physiologic assessment were performed before and at 3, 6, and 12 months after operation. RESULTS: Improvement of continence was similar. Bowel regulation problems which were unchanged after the Ripstein procedure increased significantly after the Wells procedure (P<0.01). Rectal volume became reduced in the group who received the Wells procedure (225 mlvs. 115 ml, P<0.05 at one year), but remained unchanged after receiving the Ripstein procedure. The pressure thresholds required to elicit sensation of rectal filling and defecation urge were increased after the Wells procedure (15 cm of H₂Ovs. 25 cm of H₂O, P<0.05 and 25 cm of H₂O vs. 45 cm of H₂O, P<0.05, respectively). In the Ripstein group there was only a slight increase of the threshold for urge (P<0.05). CONCLUSION: The Wells procedure was followed by severe rectal dysfunction accompanied by increased constipation and evacuation problems. The Ripstein procedure, preserving the lateral ligaments, appears not to affect such symptoms adversely. On the other hand, improvement is not likely to occur.Supported by grants from the Swedish Medical Research Council (17X-03117), University of Gothenburg, Gothenburg Medical Society, and Assar Gabrielsson's Fund.     

A critical review of mesh kits for prolapse repairs

Demographic trends in the United States clearly indicate an aging population; therefore, a steady percentage of women with pelvic floor dysfunction suggests that ever-increasing numbers of women will seek treatment for conditions such as pelvic prolapse. Surgical techniques have rapidly evolved in recent years to include multiple proprietary kits that purport to facilitate repair using synthetic graft implants in minimally invasive fashion. Most of these products have entered the market so quickly that scientific literature lags behind with evidence to document safety and efficacy. We initially intended to examine recent publications on surgical kits for pelvic prolapse repair, but realized that, although numerous clinicians are collecting data and publishing sporadically, most information is now only available in abstract form. Therefore, this article focuses on the Apogee and Perigee systems (American Medical Systems, Minnetonka, MN), Avaulta (Bard Urological, Covington, GA), Gynecare Prolift (Ethicon, Somerville, NJ), and USS Posterior Intravaginal Slingplasty system (Tyco Healthcare, US Surgical, Norwalk, CT).     

Anterior resection for complete rectal prolapse

One hundred thirteen patients underwent anterior resection for complete rectal prolapse betwen 1968 and 1980. These patients were followed for an average of seven years; recurrence developed in eight patients (9 percent). Recurrences were found to occur at three months to eight years postoperatively, and the probability of a recurrence at two, five, and ten years was 3 percent, 6 percent, and 12 percent, respectively. Operative mortality was 1 percent and morbidity was 29 percent. Low anterior resectioin, with anastomosis in the deperitonealized portion of the colon, was found to increase morbidity without significantly decreasing recurrence when compared with high anterior resection. The effects of repair on patient continence were unpredictable. High anterior resection is preferable to low anterior resection in the treatment of rectal prolapse and offers results comparable to those of other repairs currently being performed.