Surgical Management of Full-Thickness Rectal Prolapse in the Elderly Patient

  • Francesco Gabrielli
  • Angelo Guttadauro
  • Matteo Maternini
  • Nicoletta Pecora
Chapter

Abstract

The incidence of full-thickness rectal prolapse is 1% in patients over 65 years of age. Risk factors are multiparity, previous pelvic surgery, and neurological or psychiatric disorders. IBS, constipation, and chronic straining are comorbidity factors. Symptoms and risk of complications are indications for surgical treatment. Among abdominal operations, ventral rectopexy recently seems to offer the best long-term results. Recurrence rate less than 3–4%, a net improvement of continence, is in up to 80–90% of cases; compared with traditional rectopexies, a greater improvement in constipation and a reduced risk of postoperative constipation are observed. Perineal procedures (Altemeier’s proctosigmoidectomy) are less demanding on the patients and are still the favorite technical choice in the elderly, mostly in high-risk patients. Morbidity and mortality are low and postoperative recovery is faster. If the technique is correctly performed, there seems to be no statistically significant difference in recurrence rate between abdominal and perineal procedures. However, in the last few years, there is a new emerging trend for a wider use of laparoscopic ventral rectopexy also in geriatric low-risk patients.

Keywords

Rectal prolapse Rectopexy Perineal rectosigmoidectomy 

References

  1. 1.
    Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg. 2005;94:207–10.CrossRefGoogle Scholar
  2. 2.
    Stein EA, Stein DE. Rectal procidentia: diagnosis and management. Gastrointest Endosc Clin N Am. 2006;16:189–201.CrossRefGoogle Scholar
  3. 3.
    MRB K, Williams NS. Rectal prolapse. In: Surgery of the anus rectum and colon, Saunders, vol. 23. London; 1999. p. 794–842.Google Scholar
  4. 4.
    Madoff RD, Mellgren A. One hundred years of rectal prolapse surgery. Dis Colon Rectum. 1999;42:441–50.CrossRefGoogle Scholar
  5. 5.
    Jayne D, Stuto A. The evidence for stapled hemorrhoidopexy and STARR. In: Transanal stapling techniques for anorectal prolapse, vol. 7. London: Springer; 2009. p. 95–115.CrossRefGoogle Scholar
  6. 6.
    Broden B, Snellman B. Procidentia of the rectum studied with cineradiography: a contribution to the discussion of the causative mechanism. Dis Colon Rectum. 1968;11:330–47.CrossRefGoogle Scholar
  7. 7.
    Kim DS, Tsang CB, Wong WD, et al. Complete rectal prolapse: evolution of management and results. Dis Colon Rectum. 1999;42:460–6.CrossRefGoogle Scholar
  8. 8.
    Khaikin M, Wexner SD. Treatment strategies in obstructed defecation and fecal incontinence. World J Gastroenterol. 2006;12:3168–73.CrossRefGoogle Scholar
  9. 9.
    Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg. 2005;140:63–73.CrossRefGoogle Scholar
  10. 10.
    Tou S, Brown SR, Nelson RL. Surgery for complete (full-thickness) rectal prolapse in adults. Cochrane Database Syst Rev. 2015;11:CD001758.  https://doi.org/10.1002/14651858.CD001758.pub3.CrossRefGoogle Scholar
  11. 11.
    Karas JR, Uranues S, Altomare DF, et al. No rectopexy versus rectopexy following rectal mobilization for full-thickness rectal prolapse: a randomized controlled trial. Dis Colon Rectum. 2011;54:29–34.CrossRefGoogle Scholar
  12. 12.
    Wells C. New operation for rectal prolapse. Proc R Soc Med. 1959;52:602–3.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Loygue J, Huguier M, Malafosse M, Biotois H. Complete prolapse of the rectum. A report on 140 cases treated by rectopexy. Br J Surg. 1971;58:847–8.CrossRefGoogle Scholar
  14. 14.
    Ripstein CB. Procidentia: definitive corrective surgery. Dis Colon Rectum. 1972;15:334–6.CrossRefGoogle Scholar
  15. 15.
    Novell JR, Osborne MJ, Winslet MC, Lewis AA. Prospective randomized trial of Ivalon sponge versus sutured rectopexy for full-thickness rectal prolapse. Br J Surg. 1994;81(6):904–6.CrossRefGoogle Scholar
  16. 16.
    Speakman CTM, Madden MV, Nicholls RJ, Kamm MA. Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study. Br J Surg. 1991;78(12):1431–3.CrossRefGoogle Scholar
  17. 17.
    Selvaggi F, Scotto di Carlo E, Silvestri L, Festa L, Piegari V. Surgical treatment of rectal prolapse: a randomised study. Br J Surg. 1993;80(Suppl):S89.Google Scholar
  18. 18.
    Mollen RM, Kuijpers JH, van Hoek F. Effects of rectal mobilization and lateral ligaments division on colonic and anorectal function. Dis Colon Rectum. 2000;43:1283–7.CrossRefGoogle Scholar
  19. 19.
    Watts JD, Rothenberger DA, Buls JG, et al. The management of procidentia. 30 years’ experience. Dis Colon Rectum. 1985;28:96–102.CrossRefGoogle Scholar
  20. 20.
    Madbouly KM, Senagore AJ, Delaney CP, et al. Clinically based management of rectal prolapse. Surg Endosc. 2003;17:99–103.CrossRefGoogle Scholar
  21. 21.
    Raftopoulos Y, Senagore AJ, Di Giuro G, et al. Recurrence rates after abdominal surgery for complete rectal prolapse: a multicenter pooled analysis of 643 individual patient data. Dis Colon Rectum. 2005;48:1200–6.CrossRefGoogle Scholar
  22. 22.
    Portier G, Iovino F, Lazorthes F. Surgery for rectal prolapse: Orr-Loygue ventral rectopexy with limited dissection prevents postoperative-induced constipation without increasing recurrence. Dis Colon Rectum. 2006;49:1136–40.CrossRefGoogle Scholar
  23. 23.
    Gabrielli F, Campanelli GP, Leopaldi E, Poggi L, et al. Terapia chirurgica del prolasso rettale: vantaggi e limiti delle rettopessie per via addominale. Chirurgia. 1993;6:535–40.Google Scholar
  24. 24.
    Lechaux JP, Atienza P, Goasguen N, et al. Prosthetic rectopexy to the pelvic floor and sigmoidectomy for rectal prolapse. Am J Surg. 2001;182:465–9.CrossRefGoogle Scholar
  25. 25.
    Laubert T, Kleemann M, Schorcht A, et al. Laparoscopic resection rectopexy for rectal prolapse: a single-center study during 16 years. Surg Endosc. 2010;24:2401–6.CrossRefGoogle Scholar
  26. 26.
    Dulucq JL, Wintringer P, Mahajna A. Clinical and functional outcome of laparoscopic posterior rectopexy (Wells) for full-thickness rectal prolapse. A prospective study. Surg Endosc. 2007;21:2226–30.CrossRefGoogle Scholar
  27. 27.
    Lechaux D, Trebuchet G, Siproudhis L, Campion JP. Laparoscopic rectopexy for full-thickness rectal prolapse: a single-institution retrospective study evaluating surgical outcome. Surg Endosc. 2005;19:514–8.CrossRefGoogle Scholar
  28. 28.
    Frykman HM, Goldberg SM. The surgical treatment of rectal procidentia. Surg Gynecol Obstet. 1969;129:1225–30.PubMedGoogle Scholar
  29. 29.
    Luukkonen P, Mikkonen U, Jarvinen H. Abdominal rectopexy with sigmoidectomy versus rectopexy alone for rectal prolapse: a prospective, randomized study. Int J Color Dis. 1992;7(4):219–22.CrossRefGoogle Scholar
  30. 30.
    Tjandra JJ, Fazio VW, Church JM, Milsom JW, Oakley JR, Lavery IC. Ripstein procedure is an effective treatment for rectal prolapse without constipation. Dis Colon Rectum. 1993;36:501–7.CrossRefGoogle Scholar
  31. 31.
    Senapati A, Gray RG, Middleton LJ, Harding J, Hills RK, Armitage NCM, et al. PROSPER: a randomised comparison of surgical treatments for rectal prolapse. Color Dis. 2013;15(7):858–68.CrossRefGoogle Scholar
  32. 32.
    Yoshioka K, Heyen F, Keighley MRB. Functional results after posterior abdominal rectopexy for rectal prolapse. Dis Colon Rectum. 1989;32:835–8.CrossRefGoogle Scholar
  33. 33.
    D’Hoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg. 2004;91:1500–5.CrossRefGoogle Scholar
  34. 34.
    D’Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc. 2006;20:1919–23.CrossRefGoogle Scholar
  35. 35.
    Boons P, Collinson R, Cunningham C, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation. Color Dis. 2010;12:526–32.CrossRefGoogle Scholar
  36. 36.
    Wijffels N, Cunningham C, Dixon A, Greenslade G, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse is safe and effective in the elderly. Does this make perineal procedures obsolete? Color Dis. 2011;13:561–6.CrossRefGoogle Scholar
  37. 37.
    Gurland B. Ventral mesh rectopexy: is this the new standard for surgical treatment of pelvic organ prolapse? Dis Colon Rectum. 2014;57:1446–7.CrossRefGoogle Scholar
  38. 38.
    Faucheron JL, Trilling B, Girard E, Sage P, Barbois S, Reche F. Anterior rectopexy for full-thickness rectal prolapse: technical and functional results. World J Gastroenterol. 2015;21:5049–55.CrossRefGoogle Scholar
  39. 39.
    Samaranayake CB, Luo C, Plank AW, et al. Systematic review on ventral rectopexy for rectal prolapse and intussusception. Color Dis. 2010;12:504–12.CrossRefGoogle Scholar
  40. 40.
    van Geluwe B, Wolthuis A, Penninckx F, D’Hoore A. Lessons learned after more than 400 laparoscopic ventral rectopexies. Acta Chir Belg. 2013;113:103–6.PubMedGoogle Scholar
  41. 41.
    Bjerke T, Mynster T. Laparoscopic ventral rectopexy in an elderly population with external rectal prolapse: clinical and anal manometric results. Int J Color Dis. 2014;29:1257–62.CrossRefGoogle Scholar
  42. 42.
    Galili Y, Rabau M. Comparison of polyglycolic acid and polypropylene mesh for rectopexy in the treatment of rectal prolapse. Eur J Surg. 1997;163:445–8.PubMedGoogle Scholar
  43. 43.
    Smart NJ, Pathak S, Boorman P, Daniels IR. Synthetic or biological mesh use in laparoscopic ventral mesh rectopexy: a systematic review. Color Dis. 2013;15:650–4.CrossRefGoogle Scholar
  44. 44.
    Evans C, Stevenson AR, Sileri P, et al. A multicenter collaboration to assess the safety of laparoscopic ventral rectopexy. Dis Colon Rectum. 2015;58:799–807.CrossRefGoogle Scholar
  45. 45.
    Bhandarkar DS. Laparoscopic rectopexy for complete rectal prolapse: mesh, no mesh or a ventral mesh? J Minimal Access Surg. 2014;10:1–3.CrossRefGoogle Scholar
  46. 46.
    Mercer-Jones MA, D’Hoore A, Dixon AR, et al. Consensus on ventral rectopexy: report of a panel of experts. Color Dis. 2014;16:82–8.CrossRefGoogle Scholar
  47. 47.
    Darzi A, Henry MM, Guillou PJ, Shorvon P, Monson JR. Stapled laparoscopic rectopexy for rectal prolapse. Surg Endosc. 1995;9:301–3.PubMedGoogle Scholar
  48. 48.
    Kariv Y, Delaney CP, Casillas S, et al. Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study. Surg Endosc. 2006;20:35–42.CrossRefGoogle Scholar
  49. 49.
    Boccasanta P, Venturi M, Barbieri S, Roviaro G. Impact of new technologies on the clinical and functional outcome of Altemeier’s procedure: a randomized, controlled trial. Dis Colon Rectum. 2006;49:652–60.CrossRefGoogle Scholar
  50. 50.
    Salkeld G, Bagia M, Solomon M. Economic impact of laparoscopic versus open abdominal rectopexy. Br J Surg. 2004;91:1188–91.CrossRefGoogle Scholar
  51. 51.
    Purkayastha S, Tekkis P, Athanasiou T, et al. A comparison of open vs. laparoscopic abdominal rectopexy for full-thickness rectal prolapse: a meta-analysis. Dis Colon Rectum. 2005;48:1930–40.CrossRefGoogle Scholar
  52. 52.
    Sajid MS, Siddiqui MRS, Baig MK. Open vs laparoscopic repair of full-thickness rectal prolapse: a re-meta-analysis. Color Dis. 2010;12:515–25.CrossRefGoogle Scholar
  53. 53.
    Munz Y, Moorthy K, Kudchadkar R, et al. Robotic assisted rectopexy. Am J Surg. 2004;187:88–9.CrossRefGoogle Scholar
  54. 54.
    Heemskerk J, de Hoog DE, van Gemert WG, et al. Robot-assisted vs. conventional laparoscopic rectopexy for rectal prolapse: a comparative study on costs and time. Dis Colon Rectum. 2007;50:1825–30.CrossRefGoogle Scholar
  55. 55.
    Mäkelä-Kaikkonen J, Rautio T, Klintrup K, Takala H, Vierimaa M, Ohtonen P, Mäkelä J. Robotic-assisted and laparoscopic ventral rectopexy in the treatment of rectal prolapse: a matched-pairs study of operative details and complications. Tech Coloproctol. 2014;18:151–5.CrossRefGoogle Scholar
  56. 56.
    Cirocco WC. The Altemeier procedure for rectal prolapse: an operation for all ages. Dis Colon Rectum. 2010;53:1618–23.CrossRefGoogle Scholar
  57. 57.
    Altemeier WA, Giuseffi J, Hoxworth P. Treatment of extensive prolapse of the rectum in aged or debilitated patients. Arch Surg. 1952;65:72–80.CrossRefGoogle Scholar
  58. 58.
    Altemeier WA, Culbertson WR, Schowengerdt C, Hunt J. Nineteen years’ experience with the one-stage perineal repair of rectal prolapse. Ann Surg. 1971;173:993–1006.CrossRefGoogle Scholar
  59. 59.
    Schoetz DJ Jr. Evolving practice patterns in colon and rectal surgery. J Am Coll Surg. 2006;203:322–7.CrossRefGoogle Scholar
  60. 60.
    Glasgow SC, Birnbaum EH, Kodner IJ, Fleshman JW Jr, Dietz DW. Recurrence and quality of life following perineal proctectomy for rectal prolapse. J Gastrointest Surg. 2008;12:1446–51.CrossRefGoogle Scholar
  61. 61.
    Altomare DF, Binda G, Ganio E, De Nardi P, Giamundo P, Pescatori M, Rectal Prolapse Study Group. Long-term outcome of Altemeier’s procedure for rectal prolapse. Dis Colon Rectum. 2009;52:698–703.CrossRefGoogle Scholar
  62. 62.
    Agachan F, Pfeiffer J, Joo JS, et al. Results of perineal procedures for the treatment of rectal prolapse. Am Surg. 1997;63:9–12.PubMedGoogle Scholar
  63. 63.
    Chun SW, Pikarsky AJ, You SY, et al. Perineal rectosigmoidectomy for rectal prolapse: role of levatorplasty. Tech Coloproctol. 2004;8:3–9.CrossRefGoogle Scholar
  64. 64.
    Williams JG, Rothenberger DA, Madoff RD, Goldberg SM. Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy. Dis Colon Rectum. 1992;35:830–4.CrossRefGoogle Scholar
  65. 65.
    Azimuddin K, Khubchandani IT, Rosen L, Stasik JJ, Riether RD, Reed JF. Rectal prolapse: a search for the “best” operation. Am Surg. 2001;67:622–7.PubMedGoogle Scholar
  66. 66.
    Habr-Gama A, Jacob CE, Jorge JM, et al. Rectal procidentia treatment by perineal rectosigmoidectomy combined with levator ani repair. Hepato-Gastroenterology. 2006;53:213–7.PubMedGoogle Scholar
  67. 67.
    Prasad ML, Pearl RK, Abcarian H, Orsay CP, Nelson RL. Perineal proctectomy, posterior rectopexy, and postanal levator repair for the treatment of rectal prolapse. Dis Colon Rectum. 1986;29:547–52.CrossRefGoogle Scholar
  68. 68.
    Deen KI, Grant E, Billingham C, Keighley MRB. Abdominal resection rectopexy with pelvic floor repair versus perineal rectosigmoidectomy and pelvic floor repair for full-thickness rectal prolapse. Br J Surg. 1994;81:302–4.CrossRefGoogle Scholar
  69. 69.
    Yoshioka K, Ogunbiyi OA, Keighley MRB. Pouch perineal rectosigmoidectomy gives better functional results than conventional rectosigmoidectomy in elderly patients with rectal prolapse. Br J Surg. 1998;85:1525–6.CrossRefGoogle Scholar
  70. 70.
    Kim M, Reibetanz J, Schlegel N, Germer CT, Jayne D, Isbert C. Perineal rectosigmoidectomy: quality of life. Color Dis. 2013;15:1000–6.CrossRefGoogle Scholar
  71. 71.
    Scherer R, Marti L, Hetzer F. Perineal stapled prolapse resection: a new procedure for external rectal prolapse. Dis Colon Rectum. 2008;51:1727–30.CrossRefGoogle Scholar
  72. 72.
    Romano G, Bianco F, Caggiano L. Modified perineal stapled rectal resection with contour transtar for full-thickness rectal prolapse. Color Dis. 2009;11:878–81.CrossRefGoogle Scholar
  73. 73.
    Tschuor C, Limani P, Nocito A, Dindo D, Clavien PA, Hahnloser D. Perineal stapled prolapse resection for external rectal prolapse: is it worthwhile in the long-term? Tech Coloproctol. 2013;17:537–40.CrossRefGoogle Scholar
  74. 74.
    Ram E, Krissi H, Zbar A, Atar E, Joubran S, Rath-wolfson L. Perineal stapled prolapse resection (PSPR) in elderly patients for external rectal prolapse: early experience. Tech Coloproctol. 2014;18:1003–7.CrossRefGoogle Scholar
  75. 75.
    Raahave D, Jensen AK, Dammegaard L, et al. Primary and repeated perineal stapled prolapse resection. Tech Coloproctol. 2016;20:853–7.CrossRefGoogle Scholar
  76. 76.
    Maternini M, Guttadauro A, Pecora N, Gabrielli F. Perineal stapled prolapse resection (PSPR) for external rectal prolapse in high morbidity patients. Ann Ital Chir. 2016;87:476–80.PubMedGoogle Scholar
  77. 77.
    Tsunoda A, Yasuda N, Yokoyama N, et al. Delorme’s procedure for rectal prolapse. Clinical and physiological analysis. Dis Colon Rectum. 2003;46:1260–5.CrossRefGoogle Scholar
  78. 78.
    Senapati A, Nicholls RJ, Thomson JP, Phillips RK. Results of Delorme’s procedure for rectal prolapse. Dis Colon Rectum. 1994;37:456–60.CrossRefGoogle Scholar
  79. 79.
    Youssef M, Thabet W, El Nakeeb A, Magdy A, Alla EA, El Nabeey MA, et al. Comparative study between Delorme operation with or without postanal repair and levatorplasty in treatment of complete rectal prolapse. Int J Surg. 2013;11:52–8.CrossRefGoogle Scholar
  80. 80.
    Hool GR, Hull TL, Fazio VW. Surgical treatment of recurrent complete rectal prolapse: a thirty-year experience. Dis Colon Rectum. 1997;40:270.CrossRefGoogle Scholar
  81. 81.
    Pikarsky AJ, Joo JS, Wexner SD, et al. Recurrent rectal prolapse: what is the next good option? Dis Colon Rectum. 2000;43:1273–6.CrossRefGoogle Scholar
  82. 82.
    Steele SR, Goetz LH, Minami S, et al. Management of recurrent rectal prolapse: surgical approach influences outcome. Dis Colon Rectum. 2006;49:440–5.CrossRefGoogle Scholar
  83. 83.
    Hotouras A, Ribas Y, Zakeri S, et al. A systematic review of the literature on the surgical management of recurrent rectal prolapse. Color Dis. 2015;17:657–64.CrossRefGoogle Scholar
  84. 84.
    Ding JH, Canedo J, Lee SH, et al. Perineal rectosigmoidectomy for primary and recurrent rectal prolapse: are the results comparable the second time? Dis Colon Rectum. 2012;55:666–70.CrossRefGoogle Scholar
  85. 85.
    Hrabe J, Gurland B. Optimizing treatment for rectal prolapse. Clin Colon Rectal Surg. 2016;29:271–6.CrossRefGoogle Scholar
  86. 86.
    Clark CE, Jupiter DC, Thomas JS, Papaconstantinou HT. Rectal prolapse in the elderly: trends in surgical management and outcomes from the American College of Surgeons National Surgical Quality Improvement Program database. J Am Coll Surg. 2012;215:709–14.CrossRefGoogle Scholar
  87. 87.
    Fang SH, Cromwell JW, Wilkins KB, et al. Is the abdominal repair of rectal prolapse safer then perineal repair in the highest risk patients? An NSQIP analysis. Dis Colon Rectum. 2012;55:1167–72.CrossRefGoogle Scholar
  88. 88.
    Germain A, Perrenot C, Scherrer ML, et al. Long-term outcome of robotic-assisted laparoscopic rectopexy for full-thickness rectal prolapse in elderly patients. Color Dis. 2014;16:198–202.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Francesco Gabrielli
    • 1
  • Angelo Guttadauro
    • 1
  • Matteo Maternini
    • 1
  • Nicoletta Pecora
    • 1
  1. 1.Department of General SurgeryUniversity of Milan Bicocca, Zucchi HospitalMonzaItaly

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