Pelvic Floor Disorders: Surgical Approach

24. Surgical Treatment of Recurrent Rectal Prolapse

Mia D. DeBarros, Steven D. Wexner and Scott R. Steele 

(1)

Department of General Surgery, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington, USA

Scott R. Steele

Email: harkersteele@mac.com

Abstract

Rectal prolapse or procidentia is a condition in which the entirety of the rectal wall protrudes through the anus. Full-thickness prolapse is a distressing and socially debilitating condition that occurs in a bimodal distribution, initially before the age of 3 years equally in both genders, and after the fifth decade of life primarily in females. The latter group represents 80–90% of adult patients diagnosed [12]. The severity of this condition varies; patients may present with a protruding mass that spontaneously reduces with standing or cessation of straining, or one that has already progressed to continual prolapse (Fig. 24.1). Management depends on the severity of the disease and can range from medical therapy and lifestyle modifications to surgical repair. The goal of surgery is to control prolapse, restore continence when possible, and prevent constipation and impaired evacuation [3]. These goals are typically achieved by returning the rectum to its normal position in the pelvis by fixing it to the presacral fascia. Surgical procedures may be broadly categorized by either the perineal approach or the abdominal approach, which are performed either open or in a laparoscopic fashion. Unfortunately, while there are over 130 different surgical procedures described to surgically repair this distressing condition, little consensus exists as to which one is the most beneficial.

24.1 Background

Rectal prolapse or procidentia is a condition in which the entirety of the rectal wall protrudes through the anus. Full-thickness prolapse is a distressing and socially debilitating condition that occurs in a bimodal distribution, initially before the age of 3 years equally in both genders, and after the fifth decade of life primarily in females. The latter group represents 80–90% of adult patients diagnosed [12]. The severity of this condition varies; patients may present with a protruding mass that spontaneously reduces with standing or cessation of straining, or one that has already progressed to continual prolapse (Fig. 24.1). Management depends on the severity of the disease and can range from medical therapy and lifestyle modifications to surgical repair. The goal of surgery is to control prolapse, restore continence when possible, and prevent constipation and impaired evacuation [3]. These goals are typically achieved by returning the rectum to its normal position in the pelvis by fixing it to the presacral fascia. Surgical procedures may be broadly categorized by either the perineal approach or the abdominal approach, which are performed either open or in a laparoscopic fashion. Unfortunately, while there are over 130 different surgical procedures described to surgically repair this distressing condition, little consensus exists as to which one is the most beneficial.

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Fig. 24.1

Full-thickness rectal prolapse. (Courtesy of Justin A Maykel)

Despite the myriad of choices for repair, recurrence rates can be as high as 47% for some of the procedures [45]. Recurrence can be classified as early - likely a result of technical issues at the time of the operation - or late, often secondary to the nature of the condition, underlying patient characteristics, or habits such as chronic straining that result in prolapse. Risk factors associated with recurrence include a technical error associated with the rectopexy or rectosigmoidectomy (including improper suture placement, failure to mobilize, inadequate resection), failure to address concomitant pelvic floor defects, underlying psychiatric disease, male gender, older age, and a higher body mass index (Box 24.1) [6]. Recurrent rectal prolapse repair can and should be approached, both in the preoperative evaluation and in the operative management, in a similar fashion to primary repair, with a few small caveats. The most commonly performed procedures for primary rectal prolapse are rectopexy with use of sutures or mesh (anterior or posterior placement) for fixation, sigmoid resection with rectopexy, Altemeier perineal rectosigmoidectomy and the Delorme procedure (perineal procedure). As the details of each procedure are discussed in depth elsewhere in this textbook, this chapter will highlight the unique aspects of caring for the patient with recurrence that must be taken into consideration when encountering this situation.

Box 24.1

Predisposing factors and anatomic correlates for recurrent rectal prolapse

• Chronic constipation

• Neurologic/infectious diseases

• Gender

• Parity

• Redundant rectosigmoid colon

• Deep pouch of Douglas

• Patulous anus

• Diastasis of the levator ani

• Loss of sacral fixation

• Technical error

24.2 Preoperative Evaluation and Patient Selection

When approaching the patient with recurrent rectal prolapse, it is important to first determine whether or not any surgery is required at all. Depending on the degree of recurrent prolapse and symptoms, observation or simple serial band ligation of mucosal prolapse has shown excellent results [7]. As with any disease process, all evaluations should begin with a thorough history and physical examination, taking into account the overall clinical condition of the patient. Special focus during history should be upon the predominant symptom associated with the recurrence (constipation or incontinence), as this answer may guide both the work-up and the preoperative counseling regarding postoperative bowel function. While this caveat is similar to primary prolapse, focus should also be on the timing of the recurrence and changes in function following the initial operation. For example, if constipation worsened following repair, this symptom could have led to increased straining and eventual recurrence. Additionally, this symptom may prompt a constipation evaluation including transit studies and defecography that may not have been required or performed at the initial evaluation. Physical examination should focus on identifying both the prolapse and concomitant pelvic floor defects, which may have contributed to the recurrence or are de novo and need to be addressed at time of recurrent repair. Necrotic or ischemic prolapse, similar to the primary repair, is readily visualized and typically requires urgent resection (Fig. 24.2). In the elective setting, a careful assessment of sphincter function is even more important for those experiencing fecal incontinence in the setting of recurrence. In certain patients, the examination may suggest the need for ultrasound evaluation to identify any potential defect that could be addressed and improved by surgery. Furthermore, depending on the severity of the incontinence and the underlying tone/nerve function, a better option for the patient may be fecal diversion instead of another prolapse repair.

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Fig. 24.2

Incarcerated rectal prolapse. (Courtesy of Isaac Felemovicious)

Endoscopy is recommended prior to surgical repair to exclude neoplasia in those patients at risk or with unusual symptoms. Endoscopy may also be useful to exclude conditions such as a lead point or solitary rectal ulcer, an anastomotic stricture in those patients who have had a prior resection, and to determine the level of any anastomosis that may need to be resected - especially when considering a perineal resection in a patient with a prior abdominal resection rectopexy as discussed below. Adjunctive studies such as anal manometry, electromyography, pudendal nerve motor latency testing, cinedefecography, or transit time studies should be ordered based on the patient’s predominant symptoms. Additionally, they may be helpful in those patients with possible concomitant pelvic floor abnormalities such as cystocele, enterocele, or vaginal vault prolapse that may be difficult to detect on examination. Box 24.2 lists the components of a successful evaluation. Finally, it is crucial to review the prior operative note(s) to determine crucial details that may radically effect the operation, such as the use and type of mesh, extent of dissection, previous resection(s), and any technical difficulties the prior surgeon may have encountered.

Box 24.2

Preoperative evaluation of recurrent rectal prolapse

History:

• Pelvic pressure

• Tenesmus

• Incomplete evacuation

• Constipation

• Incontinence

Physical examination:

• Visual exam of perianal area

• Digital rectal exam

• Sphincter tone and levator muscle assessment

• Valsalva maneuvers

• Identification of rectocele, cystocele, uterine prolapse

Adjunctive tests:

• Incontinence:

   Manometry

   Pudendal nerve latency

   Defecography

   Endorectal ultrasound

• Constipation:

   Manometry

   Defecography

   Transit time study

   Thyroid/parathyroid function tests

24.3 Which Operative Approach for Recurrent Prolapse is Better?

Currently, there is very little reported in the literature specifically regarding the management of recurrences - with only six studies, all retrospective in nature, that directly address management of recurrent rectal prolapse (Table 24.1) [813]. Early studies consisted of small cohorts. Hool reported on 24 patients with recurrent rectal prolapse over a 30-year period. The time to recurrence from primary repair occurred within 2 years. The majority of these patients were treated with an abdominal approach (72% Ripsten Mesh repair). The overall rerecurrence rate for this group was 17% with 7 years follow-up. The authors noted that the majority of initial recurrences appeared as a result of a technical error, with mesh failure the most common cause [9]. Furthermore, altered preoperative bowel function, especially incontinence, was rarely altered following repair of the recurrence - an important counseling point for patients prior to recurrent repairs. Fengler et al. reported 14 patients with recurrent rectal prolapse that were treated over a 10-year period. Those authors found a slightly earlier average time to recurrence than the Hool group, at 14 months. Treatment of these patients involved either a perineal or an abdominal approach, with a follow-up of 50 months for either approach. At the end of the study, there was only one death and there was no recurrence in the remaining patients [8]. Overall, complications included one patient with mucosal sloughing that occurred between two anastomotic lines, and three patients with preoperative fecal incontinence had no resolution of symptoms. Pikarsky matched 27 cases of reoperative recurrent prolapse with an equal number of primary prolapse repair, utilizing a mixture of abdominal and perineal approaches with a mean follow-up of 24 months. The overall recurrence rate between the recurrent repair and primary repair was similar (15% vs. 11%) [10].

Table 24.1

Recurrent Rectal Prolapse: Literature Reports

Study [Reference]

No. of patients

Approach

Recurrence rate (%)

Hool et al. (1997) [9]

24

Abdominal > perineal

17

Fengler et al. (1997) [8]

14

Perineal > abdominal

0

Pikarsky et al. (2000) [10]

27

Abdominal and perineal

15

Watts and Thompson (2000) [12]

17

Perineal

NA

Steele et al. (2006) [11]

78

Perineal > abdominal

37, 15

Ding et al. (2012) [13]

23

Perineal

39

To try to determine if there was a better surgical strategy when approaching a recurrent prolapse repair, Steele and colleagues analyzed a cohort of 685 patients over a 14-year period and identified 78 recurrences that underwent surgical repair utilizing a perineal approach (n = 51) or an abdominal approach (n = 27). Overall, 29% of patients developed a second recurrence, with a statistically higher rate of re-recurrence in the perineal approach group (37% vs. 15%, p = 0.03). The authors noted that recurrence after primary repair occurred at an average of 33 months, which was much longer than prior studies. Moreover, the time to second recurrence occurred at an average of 9 months. The authors of that study concluded that the abdominal approach should be utilized for recurrent prolapse repairs when the patient’s risk profile permitted, due to the much lower re-recurrence rate [11]. When comparing complications, rates of both major and minor postoperative morbidity were similar between perineal and abdominal approaches.

For patients unable to tolerate an abdominal approach for their recurrence repair, the perineal rectosigmoidectomy still offers a useful alternative. Although associated with worse functional results and higher recurrence rates, it is associated with lower morbidity rates, shorter hospital stays, and less postoperative pain compared with an abdominal approach. A recent retrospective study by Ding and associates evaluated the safety and efficacy of redo perineal rectosigmoidectomy in 23 patients and compared them with 113 case-matched patients undergoing primary repair over a 9-year period. The authors noted that while postoperative complications rates were similar (17.4% vs. 16.8%), the rate of recurrence was much higher in the redo repair group (39.1% vs. 17.7%, p = 0.007), with a shorter interval of time to recurrence compared with primary repair (16.0 months vs. 21.5 months). The authors concluded that this approach was safe and feasible in patients who would otherwise be unable to tolerate an abdominal procedure; however, the rate of recurrence would likely be considerably higher than primary repair [13].

While there is still not a consensus in the literature regarding the optimal approach for a recurrence repair, the literature suggests that the technical errors are usually, but not always, the cause of initial recurrence, time to recurrence is shorter than that of a primary repair, and abdominal repairs have lower recurrence rates compared with the perineal approach for redo recurrence repairs. The perineal approach, while having a significantly higher recurrence rate, is still a feasible alternative for patients with severe co-morbidities who are unable to undergo an abdominal approach repair. Finally, abdominal repairs can be performed via laparoscopy or traditional open routes, although only case reports currently exist for the minimally invasive approach in the setting of recurrent disease [14].

While the data may be sparse, in order to determine the ideal approach for patients with recurrence, the outcome of evaluation must be taken into account. Whether it is the complication rate, mortality, functional results, cost, or subsequent recurrences, there is a fine balance among the various surgical options for each metric. As an example, Delorme’s procedure, in general, is associated with high rate of recurrence (> 50%) in the setting of recurrent disease; however, the morbidity is often < 10% and there is no anastomosis to be concerned about. Therefore, sacrificing benefits on one aspect may allow improvements in another area, and should be viewed within the context of the individual patient.

24.4 Pearls and Pitfalls

There are technical points to consider when performing surgery for recurrence. As previously discussed, pelvic floor disorders should be identified during the preoperative evaluation and dealt with during the repair, or they may lead to recurrence. Even if not addressed, these issues can be discussed with the patient during preoperative counseling - specifically regarding the potential need for future additional surgical intervention should they become symptomatic. The value of a detailed operative report from the previous initial repair cannot not be overemphasized, and allows the surgeon to determine the type of repair, if prosthetic material was utilized, and whether or not pelvic floor pathology was present, repaired, and in what manner. The unexpected discovery of mesh tightly adhered to the sacrum during an attempt to perform a laparoscopic recurrent repair may prompt quick conversion to open or excessive bleeding in either setting.

From a pure technical aspect, there remains a fine balance between attempting to mobilize or resect more bowel, with the goal of lowering recurrence rates, with that of taking too much and leading to increased anastomotic complications. Conversely, leaving behind excess bowel may ensure adequate vascularization or a tension-free anastomosis, but often leads to a higher rate of recurrence. Certain other technical considerations can also affect recurrence rates. During Altemeier repairs, failure to enter the peritoneal cavity has been associated with higher recurrence rates [15]. During performance of an abdominal approach for repair, emphasis should be placed on the preservation of the superior hemorrhoidal artery in order to maintain adequate blood supply to the new anastomosis. Additionally, extensive distal lateral dissection may decrease recurrence rates, but may worsen or cause constipation [16]. Ischemic complications can further be minimized by resecting the prior anastomosis, especially when performing perineal rectosigmoidectomy in someone with a prior perineal rectosigmoidectomy or an abdominal resection rectopexy. Failure to do so may result in an ischemic segment, which may cause mucosal sloughing, anastomotic leak, or stricture [6]. Experience is always an asset and consultation or referral to experienced center is not considered a failure, but likely an expression of good judgment.

Finally, the key factor in overall recurrence rates remains length of time from surgery. A review of 643 abdominal prolapse repair procedures was evaluated with a mean follow-up of 43 months. The 1-year, 5-year, and 10-year recurrence rates were 1%, 6.6%, and 28.9%, respectively. The authors noted that technique, method of rectopexy, or manner of intra-abdominal approach (open vs. laparoscopic) did not have an impact on recurrence, but the length of follow-up did [17]. Furthermore, despite excellent technical success with recurrent repairs (similar to the open), the subsequent function may not improve, and may actually worsen. Accordingly, patients should be counseled very carefully regarding postoperative expectations, specifically that while a successful repair may relieve the prolapse, symptoms of constipation or incontinence are likely to remain present and that the rate of recurrence will also increase as time passes; thus emphasizing the importance of continued postoperative follow-up.

24.5 Summary

In summary, despite the paucity of large-scale trials and level-I evidence, when managing the patient with recurrent rectal prolapse, there are several conclusions that may be drawn from the existing body of reported experience. First, recurrent prolapse most commonly occurs anywhere from 1–3 years from the initial operation, although it likely increases with even longer follow-up periods. Second, a thorough work-up for these patients including adjunctive tests is required to identify factors that led to recurrence and may need to be addressed prior to or along with a subsequent repair. These factors include severe constipation or incontinence and concomitant pelvic floor disorders. A detailed review of the operative report from the initial and any prior operations is extremely useful and can identify factors that may require intraoperative evaluation and should not be repeated during surgery. Patients should be extensively counseled concerning postoperative expectations regarding associated symptoms with their recurrent prolapse, their expected higher rated recurrence regardless of approach, and the need for prolonged follow-up after the procedure. Next, technical aspects such as resection of the prior anastomosis and maintaining a fine balance between resection of redundant bowel and ensuring a tension-free anastomosis should help prevent higher rates of postoperative complications and recurrence. Finally, abdominal approaches are consistently associated with lower rates of recurrence, even following repair of recurrence. This approach should be attempted if patient risk profile permits. If an abdominal operation is not possible, then a perineal approach is still a safe and feasible procedure, albeit at a cost of a higher recurrence rate and less optimal function.

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