doi:10.1111/codi.12946
Systematic review
A systematic review of the literature on the surgical management of recurrent rectal prolapse A. Hotouras*†, Y. Ribas‡, S. Zakeri†, C. Bhan†, S. D. Wexner§, C. L. Chan* and J. Murphy¶ *Academic Surgical Unit, Royal London Hospital, London, UK †Department of Surgery, Whittington Hospital NHS Trust, London, UK, ‡Department of Surgery, Consorci Sanitari de Terrassa, Terrassa, Barcelona, Spain §Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA and ¶Physiology Unit, St Mark’s Hospital, London, UK Received 7 November 2014; accepted 21 January 2015; Accepted Article online 14 March 2015
Abstract Aim There are no available guidelines to support surgical decision-making in recurrent rectal prolapse. This systematic review evaluated the results of abdominal or perineal surgery for recurrent rectal prolapse, with the aim of developing an evidence-based treatment algorithm. Method PubMed and MEDLINE databases were searched for all clinical studies involving patients who underwent surgery for recurrent rectal prolapse between 1950 and 2014. The primary outcome measure was the recurrence rate after abdominal or perineal surgery for recurrent rectal prolapse. Secondary outcomes included morbidity, mortality and quality of life data where available. Results There were no randomized controlled studies comparing the success rates of abdominal or perineal surgery for recurrent rectal prolapse. Most studies were heterogeneous, of low quality (level IV) and involved small numbers of patients. The follow-up of 144
Introduction The exact prevalence of recurrent rectal prolapse after initial surgery is unknown although some studies have estimated that 20 30% of patients who undergo surgery for primary rectal prolapse fail, the overwhelming majority of whom are female [1–3]. The pathophysiology of the condition is far from understood and the natural history of the disorder is unclear [4,5]. The high recurrence rates after many operations are likely to be due to technical failure secondary to the presence of a redundant colon or inadequate fixation. Inherent Correspondence to: Alexander Hotouras BSc, MSc, MBBS (Lon), MRCS (Eng) MD (Res), Academic Surgical Unit, Barts Health NHS Trust, National Centre for Bowel Research and Surgical Innovation, Barts and the London School of Medicine and Dentistry, 2 Newark Street, London E12AT, UK. E-mail: [email protected]
patients included in the studies undergoing perineal surgery ranged from 8.8 to 81 months, with recurrence rates varying from 0% to 50%. Morbidity ranged from 0% to 17% with no mortality reported. Limited data on quality of life following the Altemeier procedure were available. The follow-up for 158 patients included in the studies who underwent abdominal surgery ranged from 0 to 23 years, during which recurrence rates varied from 0% to 15%. Morbidity rates ranged from 0% to 32% with 4% mortality. No quality of life data were available for patients undergoing abdominal surgery. Conclusion This systematic review was unable to develop a treatment algorithm for recurrent rectal prolapse due to the variety of surgical techniques described and the low level of evidence within heterogeneous studies. Larger high-quality studies are necessary to guide practice in this difficult area. Keywords Recurrent rectal prolapse, Delorme’s, Altemeier’s
patient factors inadequately treated such as colonic dysmotility and chronic straining may also contribute to recurrence [1–3]. The literature demonstrates not only a failure to understand fully the aetiology of recurrent prolapse but also the lack of international guidelines or consensus among coloproctologists [6–8]. Despite the paucity of robust evidence-based guidelines, perineal procedures such as Delorme’s or Altemeier’s operations are commonly used in elderly or frail patients, with abdominal procedures reserved for younger and fitter patients [6–8]. Perineal procedures are anecdotally associated with fewer postoperative complications and reduced hospital length of stay but they are thought to have a higher recurrence rate [9]. This assumption has recently been called into question in a pragmatic, factorial (2 9 2), randomized controlled trial assessing surgery for primary rectal prolapse that demonstrated
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Human studies identified through database search: time period 1950–2014 n = 20 Studies excluded n = 1; abstracts unavailable Abstracts screened n = 19 Studies excluded • n = 3; irrelevant (not adult, not recurrent) Full texts screened for eligibility n = 16 Studies excluded •
n = 2; irrelevant (not recurrent)
Studies included in the final review n = 14
Figure 1 Flow diagram of the search strategy.
no significant difference in recurrence, bowel function and quality of life between any perineal (Altemeier’s or Delorme’s) or abdominal (suture or resection rectopexy) approach [1]. Equivalent trials for recurrent rectal prolapse are awaited. Consequently, the aim of this systematic review was to evaluate defined aspects of surgical outcome following abdominal and perineal surgery for recurrent rectal prolapse. Data were analysed with the intent of developing an evidenced-based treatment algorithm that would guide decision-making for the individual patient when surgery for recurrent rectal prolapse is being considered.
Method A search of PubMed and MEDLINE databases was performed in May 2014 to identify all studies investigating the outcome of surgery for recurrent rectal prolapse. A clinical trials database (www.clinicaltrials.gov) was also searched for randomized controlled trials. The search strategy included the text terms ‘recurrent rectal prolapse’, ‘surgery’, ‘perineal’ and ‘abdominal’, spanning 1950 2014. The search strategy was restricted to articles written in English, with available abstracts, only involving human adult subjects. Furthermore, if an abstract or full manuscript was determined as being irrelevant (children or patients with primary rather than recurrent rectal prolapse), it was excluded from the final
658
analysis. Selected articles were also cross-referenced by hand. A diagrammatic illustration of the search process is shown in Fig. 1. Two reviewers (AH and YR) qualitatively assessed all studies using the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. Any disagreements were settled by consensus.
Results The initial literature search revealed 20 studies, but after the exclusion of those that did not meet the inclusion criteria of this systematic review (Fig. 1), 14 studies including 305 procedures in 300 patients were eligible for analysis (Table 1). Most of the studies were retrospective (level IV) involving only small numbers of patients. Studies were divided into perineal (Delorme’s, Altemeier’s and anal encirclement procedures) or abdominal (rectopexy with or without resection and anterior resection). A perineal approach was performed in 142 (n = 144 procedures) patients while an abdominal approach was undertaken in 158 (n = 161 procedures). Perineal procedures
Study cohort Two studies described anal encirclement and narrowing of the anal canal, also known as the Thiersch procedure, with a total of three patients in these reports [10,11]. Delor-
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, 657–664
2014
2013
2012
2012
2006
2002
Fazeli [12]
Ding [17]
Boccasanta [18]
Steele [13]
Tsugawa [20]
Year
La Greca [16]
First author
Pros
38 14 20♀/32♂ (N = 52; subgroup analysis not performed)
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, 657–664
63 2♀
CR
Retro
78 67 19 (19–95) 70♀/8♂
2
Pros
74 (32–84) 8♀
8
Retro
CR
Design
37 1♀
Age Gender
23 76 (62–90) 20♀/3♂
6
1
n
Laparoscopic rectopexy (no mesh prosthesis)
48 Altemeier procedure with (n = 23) or without (n = 25) levatorplasty 27 abdominal rectopexy with (n = 10) or without (n = 17) resection three Delorme procedure
Transobturator colonic suspension during Altemeier procedure
Altemeier procedure on 113 patients, 23 of whom had RRP
Delorme procedure on 52 patients, six of whom had RRP
Altemeier procedure combined with laparoscopic control
Procedure
Gant–Miwa operation (n = 2)
0%
Not commented on
24
8.8 (1–82)
0%
Abdominal 15%, perineal 37% (P = 0.03) 18 patients had surgery for a second recurrence
0%
30
0%
Major complications: abdominal 15%, perineal 10% (P = 0.71) Minor complications: abdominal 11%, perineal 10% (P = 0.72) No mortalities in either group
Wexner score Proctoscopy Anorectal manometry Anal EMG SF36
Altemeier procedure (n = 8)
39%
37.5
17.4% (two urinary infection, one urinary retention, one anastomotic disruption)
0%
Recurrence rates
50%
24
Follow up (months)
30
Subgroup analysis not performed. However, no mortalities or major complications reported. Minor complications reported in 15.4% of all 52 patients
0%
Complications reported
Not commented on
Not commented on
Altemeier procedure
53 Altemeier procedure (n = 53) Delorme procedure (n = 7) Thiersch (n = 1) Rectopexy with resection (n = 12) Rectopexy without resection (n = 5)
Defecography (in a group of patients) Proctoscopy, rectosigmoidoscopy or anal manometry (done selectively)
Not commented on
Preoperative assessment
Abdominal repair (n = 4) Delorme procedure (n = 2)
Two previous Altemeier procedures
Previous repairs
Table 1 Summary of studies of the management of recurrent rectal prolapse.
‘Preoperative incontinence disappeared within 1 month’ (no more data are given)
Not commented on
Significant improvement in Wexner and QoL scores postoperatively No significant changes on anal manometry
8/23 history of constipation Postoperative function not assessed
23/52 preoperative constipation. Improved in 69.6% patients 7/52 preoperative incontinence. Improved clinically in most patients (71.4%) Subgroup analysis not performed
Postoperative function not assessed formally
Functional outcomes
A. Hotouras et al.
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659
660
2000
1999
1999
1997
Araki [21]
Takesue [19]
Fengler [10]
2000
Year
Watts [15]
Pikarsky [14]
First author
14
5
5
20
27
n
Table 1 (Continued).
68 (22–92) 11♀/3♂
79 (26–85) 8♀/2♂ (N = 10; subgroup analysis not performed)
80 (78–83) 4♀/1♂
75 (55–91) 16♀/4♂
69 14 26♀/1♂
Age Gender
Perineal proctectomy and levatorplasty (n = 7), rectopexy (n = 3), anterior resection with rectopexy (n = 2), Delorme procedure
Altemeier procedure performed in 10 patients, five of whom had RRP
Retro
Retro
Transsacral rectopexy performed with Dexon mesh
Delorme procedure performed consecutively on 101 patients, 20 of whom had RRP
27 patients undergoing RRP repair vs 27 patients undergoing primary repair Recurrent group procedures: Altemeier (n = 14), resection rectopexy (n = 8), rectopexy (n = 2), pelvic floor repair (n = 2), Delorme procedure (n = 1)
Procedure
Retro
Retro
Retro
Design
Not commented on
No morbidity reported one mortality (unrelated cause)
50 (9–115)
0%
Either 0% or 20% depending on which patient developed a further relapse after 24 months (paper did not specify)
42 (20.4–66) Anastomotic leakage (n = 1), treated conservatively
Not commented on
Thiersch operation combined with the Gant–Miwa technique (n = 4) Unknown procedure (n = 1) Perineal proctectomy and levatorplasty (n = 10) Anal encirclement
0%
12–36
0%
Pescatori score Anal manometry Defaecography
Perineal surgery (n = 2) Anal encirclement (n = 3)
50%
RRP group 14.8%. primary group 11.1% (P = NS)
Recurrence rates
16 (0–55)
Not commented on
Follow up (months)
Subgroup analysis not performed four mortality (myocardial infarction, pneumonia, haemolytic anaemia, anastomotic dehiscence)
One anastomotic leak treated conservatively (after Altemeier) one anal wound infection (after Altemeier) No significant differences in morbidity and mortality between the two groups
Complications reported
Faecal incontinence score Sigmoidoscopy
Wexner score Anal manometry Anal EMG Defaecography
Preoperative assessment
One previous Delorme procedure (n = 17) two previous Delorme procedures (n = 3)
Rectopexy (n = 7) Delorme’s procedure (n = 7) Altemeier procedure (n = 7) Anal encirclement (n = 4) Resection rectopexy (n = 2)
Previous repairs
No improvement of faecal incontinence in the three patients who suffered preoperatively
7/10 preoperative incontinence All patients became fully continent within 2 months Subgroup analysis not performed
Improvement in incontinence score, maximal resting pressure, number of patients with constipation, straining anorectal angle and perineal descent
Grade of incontinence was equal or better in 15/17 patients after a second Delorme procedure, despite recurrence rate
Postoperative Wexner score 2.8 4.8 with no difference with primary repair group (preoperative data not given)
Functional outcomes
Recurrent rectal prolapse A. Hotouras et al.
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1997
1984
1983
Hool [11]
Loygue [22]
Keighley [23]
Age Gender
26 65.3 91♀/9♂ (N = 100; subgroup analysis not performed)
61 (11–90) 200♀/57♂ (N = 257; subgroup analysis not performed)
24 56 (18–88) 19♀/5♂
n
24 patients, who had 29 RRP repairs in total (25 abdominal and four perineal repair) Ripstein (n = 18), anterior resection (n = 3), Frykman– Goldberg (n = 3), rectal suspension (n = 1), Altemeier (n = 2), anal encirclement (n = 2)
Rectopexy performed in 257 patients, 61 of whom had RRP
Marlex mesh abdominal rectopexy performed consecutively on 100 patients, 26 of whom had RRP
Retro
Retro
(n = 1) and anal encirclement (n = 1)
Procedure
Retro
Design
Follow up (months)
Subgroup analysis not performed. two mortality (myocardial infarction and pulmonary embolism). one reoperation for bleeding, three intervertebral disc infection, one pelvic sepsis requiring colostomy Subgroup analysis not performed. four wound infection reported in all 100 patients
Not commented on
Anal manometry
Thiersch procedure (n = 49) Simple colopexy (n = 10) Rectopexy (n = 5) Perineal resection (n = 2)
Thiersch wire or a Silastic perianal sling (n = 19) Rectopexy with polyvinyl alcohol sponge (Ivalon) (n = 5) Pelvic floor repair (n = 2)
0%
> 24 (in 86 patients)
67/100 patients had preoperative faecal incontinence 24/67 patients persisted with faecal incontinence Subgroup analysis not performed
121/257 patients anal incontinence preoperatively Normal continence restored in 90 patients Subgroup analysis not performed
5.6% (n = 257) Subgroup analysis not performed) 60–276 in 115 patients (subgroup analysis not performed)
Functional outcomes
6/24 patients preoperative constipation and 7/24 postoperatively 10/24 patients preoperative incontinence and 7/24 postoperatively
Recurrence rates
17%
32% morbidity in 81 (1 204) abdominal operations: wound infection (n = 2), dehiscence abdominal wound (n = 1), small bowel obstruction (n = 2), pelvic haematoma (n = 1), pulmonary embolus (n = 1), pneumonia (n = 1) 0% morbidity in perineal operations
Complications reported
Proctoscopy (all patients) Some patients: colonoscopy, barium enema, EMG, manometry
Preoperative assessment
Abdominal repair (n = 15) Perineal repair (n = 9)
(n = 2) Delorme procedure (n = 1) Anterior resection (n = 1)
Previous repairs
CR, case report; EMG, electromyography; Pros, prospective; QoL, quality of life; Retro, retrospective; RRP, recurrent rectal prolapse.
Year
First author
Table 1 (Continued).
A. Hotouras et al.
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doi:10.1111/codi.12946
Systematic review
A systematic review of the literature on the surgical management of recurrent rectal prolapse A. Hotouras*†, Y. Ribas‡, S. Zakeri†, C. Bhan†, S. D. Wexner§, C. L. Chan* and J. Murphy¶ *Academic Surgical Unit, Royal London Hospital, London, UK †Department of Surgery, Whittington Hospital NHS Trust, London, UK, ‡Department of Surgery, Consorci Sanitari de Terrassa, Terrassa, Barcelona, Spain §Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA and ¶Physiology Unit, St Mark’s Hospital, London, UK Received 7 November 2014; accepted 21 January 2015; Accepted Article online 14 March 2015
Abstract Aim There are no available guidelines to support surgical decision-making in recurrent rectal prolapse. This systematic review evaluated the results of abdominal or perineal surgery for recurrent rectal prolapse, with the aim of developing an evidence-based treatment algorithm. Method PubMed and MEDLINE databases were searched for all clinical studies involving patients who underwent surgery for recurrent rectal prolapse between 1950 and 2014. The primary outcome measure was the recurrence rate after abdominal or perineal surgery for recurrent rectal prolapse. Secondary outcomes included morbidity, mortality and quality of life data where available. Results There were no randomized controlled studies comparing the success rates of abdominal or perineal surgery for recurrent rectal prolapse. Most studies were heterogeneous, of low quality (level IV) and involved small numbers of patients. The follow-up of 144
Introduction The exact prevalence of recurrent rectal prolapse after initial surgery is unknown although some studies have estimated that 20 30% of patients who undergo surgery for primary rectal prolapse fail, the overwhelming majority of whom are female [1–3]. The pathophysiology of the condition is far from understood and the natural history of the disorder is unclear [4,5]. The high recurrence rates after many operations are likely to be due to technical failure secondary to the presence of a redundant colon or inadequate fixation. Inherent Correspondence to: Alexander Hotouras BSc, MSc, MBBS (Lon), MRCS (Eng) MD (Res), Academic Surgical Unit, Barts Health NHS Trust, National Centre for Bowel Research and Surgical Innovation, Barts and the London School of Medicine and Dentistry, 2 Newark Street, London E12AT, UK. E-mail: [email protected]
patients included in the studies undergoing perineal surgery ranged from 8.8 to 81 months, with recurrence rates varying from 0% to 50%. Morbidity ranged from 0% to 17% with no mortality reported. Limited data on quality of life following the Altemeier procedure were available. The follow-up for 158 patients included in the studies who underwent abdominal surgery ranged from 0 to 23 years, during which recurrence rates varied from 0% to 15%. Morbidity rates ranged from 0% to 32% with 4% mortality. No quality of life data were available for patients undergoing abdominal surgery. Conclusion This systematic review was unable to develop a treatment algorithm for recurrent rectal prolapse due to the variety of surgical techniques described and the low level of evidence within heterogeneous studies. Larger high-quality studies are necessary to guide practice in this difficult area. Keywords Recurrent rectal prolapse, Delorme’s, Altemeier’s
patient factors inadequately treated such as colonic dysmotility and chronic straining may also contribute to recurrence [1–3]. The literature demonstrates not only a failure to understand fully the aetiology of recurrent prolapse but also the lack of international guidelines or consensus among coloproctologists [6–8]. Despite the paucity of robust evidence-based guidelines, perineal procedures such as Delorme’s or Altemeier’s operations are commonly used in elderly or frail patients, with abdominal procedures reserved for younger and fitter patients [6–8]. Perineal procedures are anecdotally associated with fewer postoperative complications and reduced hospital length of stay but they are thought to have a higher recurrence rate [9]. This assumption has recently been called into question in a pragmatic, factorial (2 9 2), randomized controlled trial assessing surgery for primary rectal prolapse that demonstrated
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(n = 196) and recurrent (n = 61) rectal prolapse [22]. Steele et al. [13] reported a 15% recurrence rate for abdominal rectopexy, which was significantly lower than the perineal group. Unfortunately, other studies did not compare the abdominal with the perineal approach; thus data on recurrence for these patients were not available [11,14].
Morbidity Two studies reported no morbidity in seven patients treated by rectopexy [20,21], and in most others this was low (Table 1). After abdominal procedures Hool et al. [11] reported a morbidity rate of 32% and Steele et al. reported minor complications in 11% and major complications in 15% [13]. In the study by Loygue et al. the postoperative course was uneventful in 96% of cases, with two elderly patients dying from cardiac complications [22].
Discussion In this systematic review of the treatment of recurrent rectal prolapse, a wide range of recurrence rates was reported with only one study comparing the abdominal and perineal approaches. Steele et al. [13] reported significantly fewer recurrences in the abdominal surgery group (37% vs 15%), but patients who underwent abdominal repair in this study were significantly younger than those having perineal surgery. Although this was the largest of the studies, it was limited by its retrospective nature and the short follow-up period of 9 months. These limitations were not confined to the work of Steele et al., since most of the studies were affected by selection bias. In particular, perineal procedures were more frequently performed for older patients, who presumably were considered to be at high risk of morbidity or mortality had abdominal surgery been performed. Some authors opted for perineal surgery even in young patients but the results for recurrent rectal prolapse were disappointing [12,15]. Morbidity and mortality rates were generally low with the exception of the oldest series, although firm conclusions cannot be drawn as these were not systematically reported in most of the studies. Despite the fact that constipation and incontinence are frequently associated with prolapse, these symptoms were, unfortunately, also not assessed consistently. Sexual dysfunction that might relate to autonomic nerve injury following rectal mobilization was also not documented by any of the studies. Preoperative symptoms and assessment of other pelvic floor disorders were not routinely reported in the studies included in the review. Only three reports described preoperative defaecating proctography prior to surgery [12,14,21] but the results were not presented and the choice of the surgical
Recurrent rectal prolapse
approach did not appear to be influenced by any consideration of symptoms or coexisting pathology. In keeping with the lack of assessment of any concomitant pelvic floor pathology in most studies, previous surgery for rectal prolapse were rarely taken into account in operative planning. Only Fengler et al. [10] acknowledged previous surgery to be a variable that might influence the surgical approach. Thus they suggested that any repeat resectional procedure should remove the previous anastomosis to avoid ischaemia of the bowel. In contrast Ding et al. [17] considered an Altemeier procedure to be a reasonable option for recurrent rectal prolapse if a resection rectopexy had been performed as the index procedure, because the tissue planes are likely to be distorted and there might not be enough tissue for a rectopexy. Their reported recurrence rate following a second Altemeier procedure was 39%, which was significantly higher than in the primary group, but it should be noted that in this study only 56% of patients were examined postoperatively by a surgeon. Given that the perception that the results of surgery for recurrent rectal prolapse are frequently disappointing, some authors have modified existing surgical techniques in an attempt to improve function and to decrease the morbidity associated with surgery. Boccasanta et al. [18] reported a new operation consisting of a transobturator colonic suspension during Altemeier’s procedure, in an attempt to reduce recurrence. La Greca et al. [16] proposed that a laparoscopically assisted Altemeier procedure was superior to the standard technique as laparoscopy allowed better control of the rectum and sigmoid colon and allowed ischaemia to be diagnosed in the acute setting. Unfortunately only one of the assessed articles addressed the role of laparoscopy in the elective management of recurrent prolapse [20]. Consequently, while laparoscopy may offer benefits over laparotomy for older patients, the traditional concept that older or high-risk patients should be offered a perineal procedure cannot currently be challenged in the laparoscopic era. This systematic review has important limitations. Most studies are retrospective with no obvious treatment algorithm to follow, assessing small numbers of patients with variable lengths of follow-up. While median follow-up could not be calculated in our review, for five of the six studies with no recurrence the median postoperative follow-up was < 30 months [16,18,20,21,23]. This is particularly concerning as data from studies assessing intervention for primary rectal prolapse suggest recurrence may occur up to 10 years after surgery [24,25]. Another important limitation is that a number of studies included primary and recurrent rectal prolapse but did not perform subgroup analysis. Likewise, studies assessing different surgical techniques did not separate the
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analysis of abdominal and perineal approaches. Finally, the assessment of function and quality of life was not consistently reported by most studies, which mainly focused on postoperative recurrence. This systematic review cannot provide a treatment algorithm for recurrent rectal prolapse owing to the variety of surgical techniques described and the low level of evidence within heterogeneous studies. Consequently, the surgeon should tailor intervention for the individual patient according to their clinical competence, taking previous surgery into account. At present abdominal and perineal approaches can both be justified until high-quality studies are available.
Author contributions All authors contributed to the literature review and the preparation of this manuscript. AH and YR contributed equally and should be considered joint first authors.
Conflict of interest None declared.
References 1 Senapati A, Gray RG, Middleton LJ et al. PROSPER: a randomized comparison of surgical treatments for rectal prolapse. Colorectal Dis 2013; 15: 858–68. 2 Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg 2005; 94: 207–10. 3 Kim DS, Tsang CB, Wong WD, Lowry AC, Goldberg SM, Madoff RD. Complete rectal prolapse: evolution of management and results. Dis Colon Rectum 1999; 42: 460–6 discussion 466 9. 4 Hotouras A, Murphy J, Boyle DJ, Allison M, Williams NS, Chan CL. Assessment of female patients with rectal intussusception and prolapse: is this a progressive spectrum of disease? Dis Colon Rectum 2013; 56: 780–5. 5 Wijffels NA, Collinson R, Cunningham C, Lindsey I. What is the natural history of internal rectal prolapse? Colorectal Dis 2010; 12: 822–30. 6 Tou S, Brown SR, Malik AI, Nelson RL. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev 2008: CD001758. 7 Hammond K, Beck DE, Margolin DA, Whitlow CB, Timmcke AE, Hicks TC. Rectal prolapse: a 10-year experience. Ochsner J 2007; 7: 24–32. 8 Rashid Z, Basson MD. Association of rectal prolapse with colorectal cancer. Surgery 1996; 119: 51–5. 9 Xynos E. Functional results after surgery for overt rectal prolapse. Acta Chir Iugosl 2012; 59: 21–4. 10 Fengler SA, Pearl RK, Prasad ML et al. Management of recurrent rectal prolapse. Dis Colon Rectum 1997; 40: 832–4.
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11 Hool GR, Hull TL, Fazio VW. Surgical treatment of recurrent complete rectal prolapse: a thirty-year experience. Dis Colon Rectum 1997; 40: 270–2. 12 Fazeli MS, Kazemeini AR, Keshvari A, Keramati MR. Delorme’s procedure: an effective treatment for a full-thickness rectal prolapse in young patients. Ann Coloproctol 2013; 29: 60–5. 13 Steele SR, Goetz LH, Minami S, Madoff RD, Mellgren AF, Parker SC. Management of recurrent rectal prolapse: surgical approach influences outcome. Dis Colon Rectum 2006; 49: 440–5. 14 Pikarsky AJ, Joo JS, Wexner SD et al. Recurrent rectal prolapse: what is the next good option? Dis Colon Rectum 2000; 43: 1273–6. 15 Watts AM, Thompson MR. Evaluation of Delorme’s procedure as a treatment for full-thickness rectal prolapse. Br J Surg 2000; 87: 218–22. 16 La Greca G, Sofia M, Primo S, Randazzo V, Lombardo R, Russello D. Laparoscopic implementation of the Altemeier procedure for recurrent rectal prolapse. Int J Surg Case Rep 2014; 5: 347–9. 17 Ding JH, Canedo J, Lee SH, Kalaskar SN, Rosen L, Wexner SD. Perineal rectosigmoidectomy for primary and recurrent rectal prolapse: are the results comparable the second time? Dis Colon Rectum 2012; 55: 666–70. 18 Boccasanta P, Venturi M, Spennacchio M, Fratus G, Despini L, Roviaro G. Trans-obturator colonic suspension during Altemeier’s operation for full-thickness rectal prolapse: preliminary results with a new technique. Colorectal Dis 2012; 14: 616–22. 19 Takesue Y, Yokoyama T, Murakami Y et al. The effectiveness of perineal rectosigmoidectomy for the treatment of rectal prolapse in elderly and high-risk patients. Surg Today 1999; 29: 290–3. 20 Tsugawa K, Sue K, Koyanagi N et al. Laparoscopic rectopexy for recurrent rectal prolapse: a safe and simple procedure without a mesh prosthesis. Hepatogastroenterology 2002; 49: 1549–51. 21 Araki Y, Isomoto H, Tsuzi Y et al. Transsacral rectopexy for recurrent complete rectal prolapse. Surg Today 1999; 29: 970–2. 22 Loygue J, Nordlinger B, Cunci O, Malafosse M, Huguet C, Parc R. Rectopexy to the promontory for the treatment of rectal prolapse. Report of 257 cases. Dis Colon Rectum 1984; 27: 356–9. 23 Keighley MR, Fielding JW, Alexander-Williams J. Results of Marlex mesh abdominal rectopexy for rectal prolapse in 100 consecutive patients. Br J Surg 1983; 70: 229–32. 24 Eu KW, Seow-Choen F. Functional problems in adult rectal prolapse and controversies in surgical treatment. Br J Surg 1997; 84: 904–11. 25 Raftopoulos Y1, Senagore AJ, Di GG, Bergamaschi R, Rectal Prolapse Recurrence Study Group. 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.
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, 657–664
Systematic review
A systematic review of the literature on the surgical management of recurrent rectal prolapse A. Hotouras*†, Y. Ribas‡, S. Zakeri†, C. Bhan†, S. D. Wexner§, C. L. Chan* and J. Murphy¶ *Academic Surgical Unit, Royal London Hospital, London, UK †Department of Surgery, Whittington Hospital NHS Trust, London, UK, ‡Department of Surgery, Consorci Sanitari de Terrassa, Terrassa, Barcelona, Spain §Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA and ¶Physiology Unit, St Mark’s Hospital, London, UK Received 7 November 2014; accepted 21 January 2015; Accepted Article online 14 March 2015
Abstract Aim There are no available guidelines to support surgical decision-making in recurrent rectal prolapse. This systematic review evaluated the results of abdominal or perineal surgery for recurrent rectal prolapse, with the aim of developing an evidence-based treatment algorithm. Method PubMed and MEDLINE databases were searched for all clinical studies involving patients who underwent surgery for recurrent rectal prolapse between 1950 and 2014. The primary outcome measure was the recurrence rate after abdominal or perineal surgery for recurrent rectal prolapse. Secondary outcomes included morbidity, mortality and quality of life data where available. Results There were no randomized controlled studies comparing the success rates of abdominal or perineal surgery for recurrent rectal prolapse. Most studies were heterogeneous, of low quality (level IV) and involved small numbers of patients. The follow-up of 144
Introduction The exact prevalence of recurrent rectal prolapse after initial surgery is unknown although some studies have estimated that 20 30% of patients who undergo surgery for primary rectal prolapse fail, the overwhelming majority of whom are female [1–3]. The pathophysiology of the condition is far from understood and the natural history of the disorder is unclear [4,5]. The high recurrence rates after many operations are likely to be due to technical failure secondary to the presence of a redundant colon or inadequate fixation. Inherent Correspondence to: Alexander Hotouras BSc, MSc, MBBS (Lon), MRCS (Eng) MD (Res), Academic Surgical Unit, Barts Health NHS Trust, National Centre for Bowel Research and Surgical Innovation, Barts and the London School of Medicine and Dentistry, 2 Newark Street, London E12AT, UK. E-mail: [email protected]
patients included in the studies undergoing perineal surgery ranged from 8.8 to 81 months, with recurrence rates varying from 0% to 50%. Morbidity ranged from 0% to 17% with no mortality reported. Limited data on quality of life following the Altemeier procedure were available. The follow-up for 158 patients included in the studies who underwent abdominal surgery ranged from 0 to 23 years, during which recurrence rates varied from 0% to 15%. Morbidity rates ranged from 0% to 32% with 4% mortality. No quality of life data were available for patients undergoing abdominal surgery. Conclusion This systematic review was unable to develop a treatment algorithm for recurrent rectal prolapse due to the variety of surgical techniques described and the low level of evidence within heterogeneous studies. Larger high-quality studies are necessary to guide practice in this difficult area. Keywords Recurrent rectal prolapse, Delorme’s, Altemeier’s
patient factors inadequately treated such as colonic dysmotility and chronic straining may also contribute to recurrence [1–3]. The literature demonstrates not only a failure to understand fully the aetiology of recurrent prolapse but also the lack of international guidelines or consensus among coloproctologists [6–8]. Despite the paucity of robust evidence-based guidelines, perineal procedures such as Delorme’s or Altemeier’s operations are commonly used in elderly or frail patients, with abdominal procedures reserved for younger and fitter patients [6–8]. Perineal procedures are anecdotally associated with fewer postoperative complications and reduced hospital length of stay but they are thought to have a higher recurrence rate [9]. This assumption has recently been called into question in a pragmatic, factorial (2 9 2), randomized controlled trial assessing surgery for primary rectal prolapse that demonstrated
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Human studies identified through database search: time period 1950–2014 n = 20 Studies excluded n = 1; abstracts unavailable Abstracts screened n = 19 Studies excluded • n = 3; irrelevant (not adult, not recurrent) Full texts screened for eligibility n = 16 Studies excluded •
n = 2; irrelevant (not recurrent)
Studies included in the final review n = 14
Figure 1 Flow diagram of the search strategy.
no significant difference in recurrence, bowel function and quality of life between any perineal (Altemeier’s or Delorme’s) or abdominal (suture or resection rectopexy) approach [1]. Equivalent trials for recurrent rectal prolapse are awaited. Consequently, the aim of this systematic review was to evaluate defined aspects of surgical outcome following abdominal and perineal surgery for recurrent rectal prolapse. Data were analysed with the intent of developing an evidenced-based treatment algorithm that would guide decision-making for the individual patient when surgery for recurrent rectal prolapse is being considered.
Method A search of PubMed and MEDLINE databases was performed in May 2014 to identify all studies investigating the outcome of surgery for recurrent rectal prolapse. A clinical trials database (www.clinicaltrials.gov) was also searched for randomized controlled trials. The search strategy included the text terms ‘recurrent rectal prolapse’, ‘surgery’, ‘perineal’ and ‘abdominal’, spanning 1950 2014. The search strategy was restricted to articles written in English, with available abstracts, only involving human adult subjects. Furthermore, if an abstract or full manuscript was determined as being irrelevant (children or patients with primary rather than recurrent rectal prolapse), it was excluded from the final
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analysis. Selected articles were also cross-referenced by hand. A diagrammatic illustration of the search process is shown in Fig. 1. Two reviewers (AH and YR) qualitatively assessed all studies using the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. Any disagreements were settled by consensus.
Results The initial literature search revealed 20 studies, but after the exclusion of those that did not meet the inclusion criteria of this systematic review (Fig. 1), 14 studies including 305 procedures in 300 patients were eligible for analysis (Table 1). Most of the studies were retrospective (level IV) involving only small numbers of patients. Studies were divided into perineal (Delorme’s, Altemeier’s and anal encirclement procedures) or abdominal (rectopexy with or without resection and anterior resection). A perineal approach was performed in 142 (n = 144 procedures) patients while an abdominal approach was undertaken in 158 (n = 161 procedures). Perineal procedures
Study cohort Two studies described anal encirclement and narrowing of the anal canal, also known as the Thiersch procedure, with a total of three patients in these reports [10,11]. Delor-
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2014
2013
2012
2012
2006
2002
Fazeli [12]
Ding [17]
Boccasanta [18]
Steele [13]
Tsugawa [20]
Year
La Greca [16]
First author
Pros
38 14 20♀/32♂ (N = 52; subgroup analysis not performed)
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, 657–664
63 2♀
CR
Retro
78 67 19 (19–95) 70♀/8♂
2
Pros
74 (32–84) 8♀
8
Retro
CR
Design
37 1♀
Age Gender
23 76 (62–90) 20♀/3♂
6
1
n
Laparoscopic rectopexy (no mesh prosthesis)
48 Altemeier procedure with (n = 23) or without (n = 25) levatorplasty 27 abdominal rectopexy with (n = 10) or without (n = 17) resection three Delorme procedure
Transobturator colonic suspension during Altemeier procedure
Altemeier procedure on 113 patients, 23 of whom had RRP
Delorme procedure on 52 patients, six of whom had RRP
Altemeier procedure combined with laparoscopic control
Procedure
Gant–Miwa operation (n = 2)
0%
Not commented on
24
8.8 (1–82)
0%
Abdominal 15%, perineal 37% (P = 0.03) 18 patients had surgery for a second recurrence
0%
30
0%
Major complications: abdominal 15%, perineal 10% (P = 0.71) Minor complications: abdominal 11%, perineal 10% (P = 0.72) No mortalities in either group
Wexner score Proctoscopy Anorectal manometry Anal EMG SF36
Altemeier procedure (n = 8)
39%
37.5
17.4% (two urinary infection, one urinary retention, one anastomotic disruption)
0%
Recurrence rates
50%
24
Follow up (months)
30
Subgroup analysis not performed. However, no mortalities or major complications reported. Minor complications reported in 15.4% of all 52 patients
0%
Complications reported
Not commented on
Not commented on
Altemeier procedure
53 Altemeier procedure (n = 53) Delorme procedure (n = 7) Thiersch (n = 1) Rectopexy with resection (n = 12) Rectopexy without resection (n = 5)
Defecography (in a group of patients) Proctoscopy, rectosigmoidoscopy or anal manometry (done selectively)
Not commented on
Preoperative assessment
Abdominal repair (n = 4) Delorme procedure (n = 2)
Two previous Altemeier procedures
Previous repairs
Table 1 Summary of studies of the management of recurrent rectal prolapse.
‘Preoperative incontinence disappeared within 1 month’ (no more data are given)
Not commented on
Significant improvement in Wexner and QoL scores postoperatively No significant changes on anal manometry
8/23 history of constipation Postoperative function not assessed
23/52 preoperative constipation. Improved in 69.6% patients 7/52 preoperative incontinence. Improved clinically in most patients (71.4%) Subgroup analysis not performed
Postoperative function not assessed formally
Functional outcomes
A. Hotouras et al.
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659
660
2000
1999
1999
1997
Araki [21]
Takesue [19]
Fengler [10]
2000
Year
Watts [15]
Pikarsky [14]
First author
14
5
5
20
27
n
Table 1 (Continued).
68 (22–92) 11♀/3♂
79 (26–85) 8♀/2♂ (N = 10; subgroup analysis not performed)
80 (78–83) 4♀/1♂
75 (55–91) 16♀/4♂
69 14 26♀/1♂
Age Gender
Perineal proctectomy and levatorplasty (n = 7), rectopexy (n = 3), anterior resection with rectopexy (n = 2), Delorme procedure
Altemeier procedure performed in 10 patients, five of whom had RRP
Retro
Retro
Transsacral rectopexy performed with Dexon mesh
Delorme procedure performed consecutively on 101 patients, 20 of whom had RRP
27 patients undergoing RRP repair vs 27 patients undergoing primary repair Recurrent group procedures: Altemeier (n = 14), resection rectopexy (n = 8), rectopexy (n = 2), pelvic floor repair (n = 2), Delorme procedure (n = 1)
Procedure
Retro
Retro
Retro
Design
Not commented on
No morbidity reported one mortality (unrelated cause)
50 (9–115)
0%
Either 0% or 20% depending on which patient developed a further relapse after 24 months (paper did not specify)
42 (20.4–66) Anastomotic leakage (n = 1), treated conservatively
Not commented on
Thiersch operation combined with the Gant–Miwa technique (n = 4) Unknown procedure (n = 1) Perineal proctectomy and levatorplasty (n = 10) Anal encirclement
0%
12–36
0%
Pescatori score Anal manometry Defaecography
Perineal surgery (n = 2) Anal encirclement (n = 3)
50%
RRP group 14.8%. primary group 11.1% (P = NS)
Recurrence rates
16 (0–55)
Not commented on
Follow up (months)
Subgroup analysis not performed four mortality (myocardial infarction, pneumonia, haemolytic anaemia, anastomotic dehiscence)
One anastomotic leak treated conservatively (after Altemeier) one anal wound infection (after Altemeier) No significant differences in morbidity and mortality between the two groups
Complications reported
Faecal incontinence score Sigmoidoscopy
Wexner score Anal manometry Anal EMG Defaecography
Preoperative assessment
One previous Delorme procedure (n = 17) two previous Delorme procedures (n = 3)
Rectopexy (n = 7) Delorme’s procedure (n = 7) Altemeier procedure (n = 7) Anal encirclement (n = 4) Resection rectopexy (n = 2)
Previous repairs
No improvement of faecal incontinence in the three patients who suffered preoperatively
7/10 preoperative incontinence All patients became fully continent within 2 months Subgroup analysis not performed
Improvement in incontinence score, maximal resting pressure, number of patients with constipation, straining anorectal angle and perineal descent
Grade of incontinence was equal or better in 15/17 patients after a second Delorme procedure, despite recurrence rate
Postoperative Wexner score 2.8 4.8 with no difference with primary repair group (preoperative data not given)
Functional outcomes
Recurrent rectal prolapse A. Hotouras et al.
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1997
1984
1983
Hool [11]
Loygue [22]
Keighley [23]
Age Gender
26 65.3 91♀/9♂ (N = 100; subgroup analysis not performed)
61 (11–90) 200♀/57♂ (N = 257; subgroup analysis not performed)
24 56 (18–88) 19♀/5♂
n
24 patients, who had 29 RRP repairs in total (25 abdominal and four perineal repair) Ripstein (n = 18), anterior resection (n = 3), Frykman– Goldberg (n = 3), rectal suspension (n = 1), Altemeier (n = 2), anal encirclement (n = 2)
Rectopexy performed in 257 patients, 61 of whom had RRP
Marlex mesh abdominal rectopexy performed consecutively on 100 patients, 26 of whom had RRP
Retro
Retro
(n = 1) and anal encirclement (n = 1)
Procedure
Retro
Design
Follow up (months)
Subgroup analysis not performed. two mortality (myocardial infarction and pulmonary embolism). one reoperation for bleeding, three intervertebral disc infection, one pelvic sepsis requiring colostomy Subgroup analysis not performed. four wound infection reported in all 100 patients
Not commented on
Anal manometry
Thiersch procedure (n = 49) Simple colopexy (n = 10) Rectopexy (n = 5) Perineal resection (n = 2)
Thiersch wire or a Silastic perianal sling (n = 19) Rectopexy with polyvinyl alcohol sponge (Ivalon) (n = 5) Pelvic floor repair (n = 2)
0%
> 24 (in 86 patients)
67/100 patients had preoperative faecal incontinence 24/67 patients persisted with faecal incontinence Subgroup analysis not performed
121/257 patients anal incontinence preoperatively Normal continence restored in 90 patients Subgroup analysis not performed
5.6% (n = 257) Subgroup analysis not performed) 60–276 in 115 patients (subgroup analysis not performed)
Functional outcomes
6/24 patients preoperative constipation and 7/24 postoperatively 10/24 patients preoperative incontinence and 7/24 postoperatively
Recurrence rates
17%
32% morbidity in 81 (1 204) abdominal operations: wound infection (n = 2), dehiscence abdominal wound (n = 1), small bowel obstruction (n = 2), pelvic haematoma (n = 1), pulmonary embolus (n = 1), pneumonia (n = 1) 0% morbidity in perineal operations
Complications reported
Proctoscopy (all patients) Some patients: colonoscopy, barium enema, EMG, manometry
Preoperative assessment
Abdominal repair (n = 15) Perineal repair (n = 9)
(n = 2) Delorme procedure (n = 1) Anterior resection (n = 1)
Previous repairs
CR, case report; EMG, electromyography; Pros, prospective; QoL, quality of life; Retro, retrospective; RRP, recurrent rectal prolapse.
Year
First author
Table 1 (Continued).
A. Hotouras et al.
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doi:10.1111/codi.12946
Systematic review
A systematic review of the literature on the surgical management of recurrent rectal prolapse A. Hotouras*†, Y. Ribas‡, S. Zakeri†, C. Bhan†, S. D. Wexner§, C. L. Chan* and J. Murphy¶ *Academic Surgical Unit, Royal London Hospital, London, UK †Department of Surgery, Whittington Hospital NHS Trust, London, UK, ‡Department of Surgery, Consorci Sanitari de Terrassa, Terrassa, Barcelona, Spain §Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA and ¶Physiology Unit, St Mark’s Hospital, London, UK Received 7 November 2014; accepted 21 January 2015; Accepted Article online 14 March 2015
Abstract Aim There are no available guidelines to support surgical decision-making in recurrent rectal prolapse. This systematic review evaluated the results of abdominal or perineal surgery for recurrent rectal prolapse, with the aim of developing an evidence-based treatment algorithm. Method PubMed and MEDLINE databases were searched for all clinical studies involving patients who underwent surgery for recurrent rectal prolapse between 1950 and 2014. The primary outcome measure was the recurrence rate after abdominal or perineal surgery for recurrent rectal prolapse. Secondary outcomes included morbidity, mortality and quality of life data where available. Results There were no randomized controlled studies comparing the success rates of abdominal or perineal surgery for recurrent rectal prolapse. Most studies were heterogeneous, of low quality (level IV) and involved small numbers of patients. The follow-up of 144
Introduction The exact prevalence of recurrent rectal prolapse after initial surgery is unknown although some studies have estimated that 20 30% of patients who undergo surgery for primary rectal prolapse fail, the overwhelming majority of whom are female [1–3]. The pathophysiology of the condition is far from understood and the natural history of the disorder is unclear [4,5]. The high recurrence rates after many operations are likely to be due to technical failure secondary to the presence of a redundant colon or inadequate fixation. Inherent Correspondence to: Alexander Hotouras BSc, MSc, MBBS (Lon), MRCS (Eng) MD (Res), Academic Surgical Unit, Barts Health NHS Trust, National Centre for Bowel Research and Surgical Innovation, Barts and the London School of Medicine and Dentistry, 2 Newark Street, London E12AT, UK. E-mail: [email protected]
patients included in the studies undergoing perineal surgery ranged from 8.8 to 81 months, with recurrence rates varying from 0% to 50%. Morbidity ranged from 0% to 17% with no mortality reported. Limited data on quality of life following the Altemeier procedure were available. The follow-up for 158 patients included in the studies who underwent abdominal surgery ranged from 0 to 23 years, during which recurrence rates varied from 0% to 15%. Morbidity rates ranged from 0% to 32% with 4% mortality. No quality of life data were available for patients undergoing abdominal surgery. Conclusion This systematic review was unable to develop a treatment algorithm for recurrent rectal prolapse due to the variety of surgical techniques described and the low level of evidence within heterogeneous studies. Larger high-quality studies are necessary to guide practice in this difficult area. Keywords Recurrent rectal prolapse, Delorme’s, Altemeier’s
patient factors inadequately treated such as colonic dysmotility and chronic straining may also contribute to recurrence [1–3]. The literature demonstrates not only a failure to understand fully the aetiology of recurrent prolapse but also the lack of international guidelines or consensus among coloproctologists [6–8]. Despite the paucity of robust evidence-based guidelines, perineal procedures such as Delorme’s or Altemeier’s operations are commonly used in elderly or frail patients, with abdominal procedures reserved for younger and fitter patients [6–8]. Perineal procedures are anecdotally associated with fewer postoperative complications and reduced hospital length of stay but they are thought to have a higher recurrence rate [9]. This assumption has recently been called into question in a pragmatic, factorial (2 9 2), randomized controlled trial assessing surgery for primary rectal prolapse that demonstrated
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(n = 196) and recurrent (n = 61) rectal prolapse [22]. Steele et al. [13] reported a 15% recurrence rate for abdominal rectopexy, which was significantly lower than the perineal group. Unfortunately, other studies did not compare the abdominal with the perineal approach; thus data on recurrence for these patients were not available [11,14].
Morbidity Two studies reported no morbidity in seven patients treated by rectopexy [20,21], and in most others this was low (Table 1). After abdominal procedures Hool et al. [11] reported a morbidity rate of 32% and Steele et al. reported minor complications in 11% and major complications in 15% [13]. In the study by Loygue et al. the postoperative course was uneventful in 96% of cases, with two elderly patients dying from cardiac complications [22].
Discussion In this systematic review of the treatment of recurrent rectal prolapse, a wide range of recurrence rates was reported with only one study comparing the abdominal and perineal approaches. Steele et al. [13] reported significantly fewer recurrences in the abdominal surgery group (37% vs 15%), but patients who underwent abdominal repair in this study were significantly younger than those having perineal surgery. Although this was the largest of the studies, it was limited by its retrospective nature and the short follow-up period of 9 months. These limitations were not confined to the work of Steele et al., since most of the studies were affected by selection bias. In particular, perineal procedures were more frequently performed for older patients, who presumably were considered to be at high risk of morbidity or mortality had abdominal surgery been performed. Some authors opted for perineal surgery even in young patients but the results for recurrent rectal prolapse were disappointing [12,15]. Morbidity and mortality rates were generally low with the exception of the oldest series, although firm conclusions cannot be drawn as these were not systematically reported in most of the studies. Despite the fact that constipation and incontinence are frequently associated with prolapse, these symptoms were, unfortunately, also not assessed consistently. Sexual dysfunction that might relate to autonomic nerve injury following rectal mobilization was also not documented by any of the studies. Preoperative symptoms and assessment of other pelvic floor disorders were not routinely reported in the studies included in the review. Only three reports described preoperative defaecating proctography prior to surgery [12,14,21] but the results were not presented and the choice of the surgical
Recurrent rectal prolapse
approach did not appear to be influenced by any consideration of symptoms or coexisting pathology. In keeping with the lack of assessment of any concomitant pelvic floor pathology in most studies, previous surgery for rectal prolapse were rarely taken into account in operative planning. Only Fengler et al. [10] acknowledged previous surgery to be a variable that might influence the surgical approach. Thus they suggested that any repeat resectional procedure should remove the previous anastomosis to avoid ischaemia of the bowel. In contrast Ding et al. [17] considered an Altemeier procedure to be a reasonable option for recurrent rectal prolapse if a resection rectopexy had been performed as the index procedure, because the tissue planes are likely to be distorted and there might not be enough tissue for a rectopexy. Their reported recurrence rate following a second Altemeier procedure was 39%, which was significantly higher than in the primary group, but it should be noted that in this study only 56% of patients were examined postoperatively by a surgeon. Given that the perception that the results of surgery for recurrent rectal prolapse are frequently disappointing, some authors have modified existing surgical techniques in an attempt to improve function and to decrease the morbidity associated with surgery. Boccasanta et al. [18] reported a new operation consisting of a transobturator colonic suspension during Altemeier’s procedure, in an attempt to reduce recurrence. La Greca et al. [16] proposed that a laparoscopically assisted Altemeier procedure was superior to the standard technique as laparoscopy allowed better control of the rectum and sigmoid colon and allowed ischaemia to be diagnosed in the acute setting. Unfortunately only one of the assessed articles addressed the role of laparoscopy in the elective management of recurrent prolapse [20]. Consequently, while laparoscopy may offer benefits over laparotomy for older patients, the traditional concept that older or high-risk patients should be offered a perineal procedure cannot currently be challenged in the laparoscopic era. This systematic review has important limitations. Most studies are retrospective with no obvious treatment algorithm to follow, assessing small numbers of patients with variable lengths of follow-up. While median follow-up could not be calculated in our review, for five of the six studies with no recurrence the median postoperative follow-up was < 30 months [16,18,20,21,23]. This is particularly concerning as data from studies assessing intervention for primary rectal prolapse suggest recurrence may occur up to 10 years after surgery [24,25]. Another important limitation is that a number of studies included primary and recurrent rectal prolapse but did not perform subgroup analysis. Likewise, studies assessing different surgical techniques did not separate the
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analysis of abdominal and perineal approaches. Finally, the assessment of function and quality of life was not consistently reported by most studies, which mainly focused on postoperative recurrence. This systematic review cannot provide a treatment algorithm for recurrent rectal prolapse owing to the variety of surgical techniques described and the low level of evidence within heterogeneous studies. Consequently, the surgeon should tailor intervention for the individual patient according to their clinical competence, taking previous surgery into account. At present abdominal and perineal approaches can both be justified until high-quality studies are available.
Author contributions All authors contributed to the literature review and the preparation of this manuscript. AH and YR contributed equally and should be considered joint first authors.
Conflict of interest None declared.
References 1 Senapati A, Gray RG, Middleton LJ et al. PROSPER: a randomized comparison of surgical treatments for rectal prolapse. Colorectal Dis 2013; 15: 858–68. 2 Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg 2005; 94: 207–10. 3 Kim DS, Tsang CB, Wong WD, Lowry AC, Goldberg SM, Madoff RD. Complete rectal prolapse: evolution of management and results. Dis Colon Rectum 1999; 42: 460–6 discussion 466 9. 4 Hotouras A, Murphy J, Boyle DJ, Allison M, Williams NS, Chan CL. Assessment of female patients with rectal intussusception and prolapse: is this a progressive spectrum of disease? Dis Colon Rectum 2013; 56: 780–5. 5 Wijffels NA, Collinson R, Cunningham C, Lindsey I. What is the natural history of internal rectal prolapse? Colorectal Dis 2010; 12: 822–30. 6 Tou S, Brown SR, Malik AI, Nelson RL. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev 2008: CD001758. 7 Hammond K, Beck DE, Margolin DA, Whitlow CB, Timmcke AE, Hicks TC. Rectal prolapse: a 10-year experience. Ochsner J 2007; 7: 24–32. 8 Rashid Z, Basson MD. Association of rectal prolapse with colorectal cancer. Surgery 1996; 119: 51–5. 9 Xynos E. Functional results after surgery for overt rectal prolapse. Acta Chir Iugosl 2012; 59: 21–4. 10 Fengler SA, Pearl RK, Prasad ML et al. Management of recurrent rectal prolapse. Dis Colon Rectum 1997; 40: 832–4.
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11 Hool GR, Hull TL, Fazio VW. Surgical treatment of recurrent complete rectal prolapse: a thirty-year experience. Dis Colon Rectum 1997; 40: 270–2. 12 Fazeli MS, Kazemeini AR, Keshvari A, Keramati MR. Delorme’s procedure: an effective treatment for a full-thickness rectal prolapse in young patients. Ann Coloproctol 2013; 29: 60–5. 13 Steele SR, Goetz LH, Minami S, Madoff RD, Mellgren AF, Parker SC. Management of recurrent rectal prolapse: surgical approach influences outcome. Dis Colon Rectum 2006; 49: 440–5. 14 Pikarsky AJ, Joo JS, Wexner SD et al. Recurrent rectal prolapse: what is the next good option? Dis Colon Rectum 2000; 43: 1273–6. 15 Watts AM, Thompson MR. Evaluation of Delorme’s procedure as a treatment for full-thickness rectal prolapse. Br J Surg 2000; 87: 218–22. 16 La Greca G, Sofia M, Primo S, Randazzo V, Lombardo R, Russello D. Laparoscopic implementation of the Altemeier procedure for recurrent rectal prolapse. Int J Surg Case Rep 2014; 5: 347–9. 17 Ding JH, Canedo J, Lee SH, Kalaskar SN, Rosen L, Wexner SD. Perineal rectosigmoidectomy for primary and recurrent rectal prolapse: are the results comparable the second time? Dis Colon Rectum 2012; 55: 666–70. 18 Boccasanta P, Venturi M, Spennacchio M, Fratus G, Despini L, Roviaro G. Trans-obturator colonic suspension during Altemeier’s operation for full-thickness rectal prolapse: preliminary results with a new technique. Colorectal Dis 2012; 14: 616–22. 19 Takesue Y, Yokoyama T, Murakami Y et al. The effectiveness of perineal rectosigmoidectomy for the treatment of rectal prolapse in elderly and high-risk patients. Surg Today 1999; 29: 290–3. 20 Tsugawa K, Sue K, Koyanagi N et al. Laparoscopic rectopexy for recurrent rectal prolapse: a safe and simple procedure without a mesh prosthesis. Hepatogastroenterology 2002; 49: 1549–51. 21 Araki Y, Isomoto H, Tsuzi Y et al. Transsacral rectopexy for recurrent complete rectal prolapse. Surg Today 1999; 29: 970–2. 22 Loygue J, Nordlinger B, Cunci O, Malafosse M, Huguet C, Parc R. Rectopexy to the promontory for the treatment of rectal prolapse. Report of 257 cases. Dis Colon Rectum 1984; 27: 356–9. 23 Keighley MR, Fielding JW, Alexander-Williams J. Results of Marlex mesh abdominal rectopexy for rectal prolapse in 100 consecutive patients. Br J Surg 1983; 70: 229–32. 24 Eu KW, Seow-Choen F. Functional problems in adult rectal prolapse and controversies in surgical treatment. Br J Surg 1997; 84: 904–11. 25 Raftopoulos Y1, Senagore AJ, Di GG, Bergamaschi R, Rectal Prolapse Recurrence Study Group. 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.
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