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D. M. Schwartzberg and M. J. Grieco

local excision or for symptomatic local recurrence.

R. Most authors agree that prophylactic inguinal

lymphadenectomy in patients with nonpalpable lymph nodes is not recommended. Controversy exists regarding lymphadenectomy of palpable or biopsy proven disease, but recent retrospective series suggest that lymphadenectomy does not improve survival.

S. There are no current trials for metastatic anal

melanoma, but one can extrapolate from cutaneous melanoma management to conclude immunotherapy or targeted therapy can be used in the setting of metastatic disease. Immunotherapy consists of Anti-PD-1 monotherapy (Pembrolizumab OR Nivolumab), or Nivolumab/ipilimumab. Targeted therapy can be used if a BRAF V600 mutation is present and consists of Dabrafenib/trametinib or Vemurafenib/cobimetinib.

T. Anal adenocarcinoma arises from the colum-

nar epithelium of the anal glands. It is rare accounting for only 1–2% of all gastrointestinal malignancies and tends to present in an advanced stage. Although its rarity precludes prospective trials, retrospective series suggest that anal adenocarcinoma should be managed liked a distal locally advanced rectal adenocarcinoma.

U. Staging requires CT scan of chest, abdomen

and pelvis.

V. For locoregional disease, neoadjuvant

chemoradiation, followed by APR with adjuvant chemotherapy.

W. For metastatic disease, 5-FU based chemo-

therapy is warranted.

X. For patients whose poor performance status

or comorbidities make them unt for radical operation, chemoradiation is recommended.

Y. Anal sarcomas mimic the symptomatology

of other anal cancers and can be intra- or extraluminal. Anal sarcoma includes differentiation such as leiomyosarcoma, brosarcoma and liposarcoma. Sarcomas are radio- resistant.

Z. Treatment for anal sarcoma is APR.

Pelvic Floor Conditions: Rectal Prolapse/Recurrence

ChristopherR.Dwyer andDipenC.Maun

Refer toAlgorithm inFig. 29.1

A. Epidemiology

Rectal prolapse is a pelvic oor disorder typically occurs in elderly, multiparous women, while in men, it typically occurs at a younger age. Although prolapse can affect people of both genders and all ages, it is an uncommon afiction with an incidence reported as low as 0.25% in the adult population and a prevalence of around 1% in adults over age 65. Colorectal surgeons at tertiary referral centers have written the majority of reported data in the literature. Other than these few experiences, little more is known about the epidemiology of the condition.

As little is known about the etiology of primary rectal prolapse, recurrent rectal prolapse continues to be an even greater enigma. The reported incidence after initial operative intervention ranges from 20–30% in some literature and up to half in others. Modern techniques note much lower recurrence rates. Patients with recurrent prolapse may require further laboratory or radiologic

C. R. Dwyer Department ofColon andRectal Surgery, Indiana University, Indianapolis, IN, USA

D. C. Maun (*) Franciscan Alliance Hospitals, Indianapolis, IN, USA e-mail: Dipen.maun@franciscanalliance.org

examination to help delineate the underlying associated pelvic oor and/or colorectal abnormalities.

B. Physiology

The underlying cause of rectal prolapse remains unclear and is a topic of debate in colorectal literature. Known risk factors for the disease include congenital or acquired and include: multiparity, pudendal nerve disorders, weak pelvic oor and anal canal muscles, weak pelvic oor ligaments, weak internal and external anal sphincters, intrinsic bowel disorders, rectocele, cystocele, or an abnormally deep pouch of Douglas. Other rare causes include neurological illnesses and connective tissue disorders.

The advent of cinedefecography in the 1960s helped colorectal surgeons dene the complex physiology of rectal prolapse. Previously postulated as a sliding pelvic oor hernia, full-thickness rectal prolapse has now been dened more as an intussusception. It is important for the colorectal surgeon to identify the correct physiologic process, as operating on the more malicious anorectal intussusception can prove disastrous for the patient and the surgeon Optimizing postoperative continence through preoperative history and physical paired with cinedefecography and manometry is paramount.

https://doi.org/10.1007/978-3-319-65942-8_29

219

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Fig. 29.1 Algorithm for rectal prolapse/recurrence

C. R. Dwyer and D. C. Maun

C. Presentation

Rectal prolapse generally presents in two forms: chronic or acute. The majority of presentations are chronic, with debilitating symptoms such as difculty maintaining perianal hygiene. Acute rectal prolapse has a more serious presentation that can include ulceration, bleeding, incarceration or gangrene. It is important to evaluate acute presentation on a more expedient basis for the proper operative intervention. In both cases, patients may complain of “something falling out” when they strain or the sensation of “sitting on a ball”.

Physical examination offers the opportunity to reduce the prolapse, which displays the classic circumferential full-thickness prolapse with concentric mucosal folds. This is appearance in contrast to the radial folds seen with hemorrhoid mucosal prolapse (Fig. 29.2). Patients will frequently have diminished resting tone and a loose, open anus. Careful digital exam should rule out other concomitant diagnoses such as rectal cancer, cystocele, rectocele, or prolapsed uterus. The surgeon should also note any excoriation of perianal skin, the adequacy of resting tone, and the function of

the puborectalis muscle on digital exam. If the prolapse is not apparent during external exam, the surgeon can have the patient sit on a toilet seat and simulate a bowel movement. This maneuver is followed up with an immediate exam in the standing position, or can be observed using a mirror or exible colonoscope aimed at the anus. Conrmation of full-thickness rectal prolapse with concentric rings of mucosa is key in making the correct diagnosis. In the acute setting (i.e., incarcerated, strangulated), initial determination needs to center around whether or not the bowel is viable or reducible, similar to other hernias. When it is non-reducible and ischemic/gangrenous, this constitutes a surgical emergency.

D. Evaluation

Prior to performing an operation for rectal prolapse, the surgeon must be aware of any concomitant chronic gastrointestinal diagnoses, which may interfere with the repair. Fortunately, there are a few diagnostic adjuncts to utilize in the pre-operative workup of rectal prolapse. A colonoscopy should be performed to exclude any other colon or rectal mucosal abnormalities, especially in

29 Pelvic Floor Conditions: Rectal Prolapse/Recurrence

Fig. 29.2 Hemorrhoid mucosal prolapse. (a) Circumferential fold consistent with full thickness rectal prolapse. (b) Radial folds representing prolapsing hemorrhoids

221

patients over the age of 50 years. Cinedefecography has been used since its inception in the 1960s, but is unnecessary unless the surgeon suspects pelvic oor muscle dysfunction or internal (rectorectal) intussusception. Anorectal manometry has become more popular with surgeons to record the mean maximal resting pressures in the upper and lower anal canal. It can also help determine sphincter continence, especially in patients with chronic prolapse causing sphincter dysfunction over time. Levatorplasty added to perineal rectosigmoidectomy has been shown to signicantly reduce postoperative episodes of incontinence when compared to perineal rectosigmoidectomy alone. Finally, patients with a history of severe constipation should undergo a colonic transit study to evaluate the proximal colon. If slow transit exists, then a concurrent sigmoid resection or subtotal colectomy with ileorectal anastomosis at the time of rectopexy may benet the patient. Pudendal nerve studies typically don’t contribute to the management of a rectal prolapse patient.

E. Treatment-Perineal Rectosigmoidectomy

A Polish surgeon named Jan Mikulicz- Radecki in 1889, only 1year after he created his famous pyloroplasty technique, performed the rst

perineal rectosigmoidectomy. Despite the early discovery, this perineal technique was not popularized until the 1970s when Altemeier described the “one stage perineal technique” in his famous Annals of Surgery publication.

The procedure is done after full cathartic bowel prep and under either local, spinal, or general anesthesia tailored to each patient’s physical status. In the lithotomy or Sims’ position, the rectum is prolapsed and injected with epinephrine-containing local anesthetic. A Lone Star® Retractor (CooperSurgical, Trumbull, CT) can efface the rectum and facilitate adequate visualization. One-to-two centimeters below the dentate line a fullthickness incision is made circumferentially around the rectal wall taking care not to injure vessels on the mesenteric side of the rectal wall. These vessels are then divided as the rectum is progressively withdrawn from the body until no further redundancy exists (Fig.29.3). The abdominal cavity is easiest to enter in the anterior plane as most patients have a deep cul-de-sac. Usage of an energy device during mesenteric ligation can allow for a quicker procedure. In cases of levator diastasis or fecal incontinence, a levatorplasty can be performed prior to the anastomosis (Fig. 29.3). Care must be taken

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C. R. Dwyer and D. C. Maun

Fig. 29.3 Perineal rectosigmoidectomy with levatorplasty (right). With permission from Williams JG, Madoff R.Perineal rectosigmoidectomy. In: O’Connell R, Madoff

not to overly tighten the levatorplasty as this can lead to outlet dysfunction. The authors suggest allowing the easy passage of a single nger between the colon and the anal oor. A colo-anal anastomosis is then performed with interrupted absorbable sutures or with a circular stapling device. The editor’s (SDW) preference is to create a colonic j pouch prior to anastomosis.

Numerous studies reporting results with case series exist in the literature since Altemeier’s rst paper in 1971. Most complications are related to the colo-anal anastomosis and include leak, suture line bleeding, pelvic abscess, and stenosis. The Minnesota group reported on a large series of over 500 procedures in varying age groups and showed an overall recurrence rate of 22.6%. Overall, the mortality tends to be fairly low and most

R, Solomon M, eds. Operative Surg Colon, Rectum, sixth edn. CRC Press, London, 2015;pp:707–714

morbidity of the operation is likely related to pre-existing medical problems.

F. Treatment - Mucosal Sleeve Resection

(Delorme) Unlike the Altemeier, the Delorme does not include full-thickness resection. The procedure was originally described in 1900 and includes a mucosal resection with muscular plication. The advantages to the Delorme are the ability to perform the procedure under spinal anesthesia and the lack of a fullthickness anastomosis. It is a good option in patients with minor prolapse, hemi circumferential prolapse and in patients with challenging abdomens.

Similar to the perineal rectosigmoidectomy, the procedure also performed after full mechanical bowel prep and under local, spinal or general anesthesia tailored

29 Pelvic Floor Conditions: Rectal Prolapse/Recurrence

223

to each patient’s physical status. The operation begins with delivering the rectal prolapse and injecting epinephrine in the submucosal plane to aid in dissection. A partial-thickness circumferential incision is made through the mucosa and a cylinder of mucosa is separated from the underlying muscularis. The extent of dissection includes the initial incision 2cm from the dentate line until there is resistance to traction on the intussusceptum. The dissected mucosal cylinder is then removed and the muscularis is plicated longitudinally. The mucosa is then re-approximated with interrupted absorbable sutures.

One of the major drawbacks of mucosal sleeve resection is high recurrence rate. Most reports in the literature range from 0–30%. In two of the larger case series, the recurrence rates were 15% and 27% with reasonable follow up. These case series show the recurrence rate is well above those of the Altemeier procedure. Recorded complications in literature remain similar to the Altemeier and include perioperative myocardial infarction, pneumonia, anastomotic dehiscence, pelvic abscess, and bleeding. A series from Cleveland Clinic Florida has shown signicantly better results with the Altemeier procedure with levatorplasty than with the Delorme procedure relative to recurrence rate, length of time until recurrence.

G. Treatment– Anal Encirclement

In 1891, a German surgeon named Thiersch offered an anal encirclement procedure in which a prosthetic was introduced around the anus and cinched down to narrow the opening. This technique has been modied since its inception. The principle feature of the operation is to tighten the widely patulous anus.

The patient is again prepped and commonly undergoes a simple local or locoregional anesthesia. Unlike the Delorme and Altemeier, Theirsch’s operation involves reducing the prolapsed rectum prior to the operation. The surgeon then places a loop of 20-gauge silver wire about the outer circum-

ference of the anal sphincter. To facilitate this maneuver, two short incisions in the anterior and posterior positions allow passage of the needle into the perianal space. The loop is then tightened down to the diameter of the proximal interphalangeal joint of the assistant’s index nger. Once in place, the surgeon twists the wire to lock its circumference and then points the sharp, cut ends of the wire up and away from the rectum toward the sacrococcygeal ligament. Modications of this technique in the 1950s utilize silver wire sleeves to avoid the sharp wire ends. More recently, Dacron vascular grafts and prosthetic mesh have been described.

The Thiersch procedure is reserved for complicated patients who are unable to undergo the aforementioned perineal procedures. It does not correct the prolapse and has serious potential morbidity including breakage of the wire, fecal impaction, erosion of the material, or pelvic sepsis. A number of papers have reported recurrence rates from 0–44%. Because of the plethora of problems, the procedure is rarely performed.

H. Treatment – Abdominal Approach

Introduction Since its inception in 1955, the abdominal approach has become the standard of care for full-thickness rectal prolapse in patients who can tolerate general anesthesia. The advent of better anesthetic techniques and minimally invasive surgery like laparoscopy and robotics have allowed us to broaden the indications and offer abdominal approaches to older and sicker patients. While myriad of approaches create an armamentarium for the colorectal surgeon to address rectal prolapse, the main goal of these procedures remains to adequately mobilize the rectum down to the levator plate. The surgical plane may play a role in xating the rectum to its normal anatomic location. Whether the lateral stalks should be divided was addressed by a Cochrane review meta-analysis. The review determined that division of the ligaments was associated with a decreased recurrence rate but increased rates of constipation.

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C. R. Dwyer and D. C. Maun

I. Treatment Posterior Sling Rectopexy

This technique was rst described by Wells in 1959 and incorporates the use of a polyvinyl alcohol sponge. This operation begins like all other transabdominal approaches: with mobilization of the rectum posteriorly down to the levator ani. An anterior dissection is performed while preserving the lateral stalks, a maneuver thought to decrease the incidence of postoperative constipation. A piece of mesh, or traditionally a polyvinyl alcohol sponge, is placed into the new rectosacral space and sutured to the presacral fascia in the middle of the mesh. After retracting the rectum cephalad, the lateral borders of the mesh are brought anteriorly creating an incomplete cylinder by xating the mesh to the anterior rectum. The peritoneal fold is then secured over the foreign body to exclude it from the abdominal cavity.

J. Treatment- Anterior Sling Rectopexy

Initially described by Ripstein in 1952, the posterior rectum is mobilized down to the levator plate; a piece of prosthetic mesh is sutured or tacked to the presacral fascia. The mesh is then wrapped around the rectum effectively creating a sling. The mesh is typically synthetic and serves as a posteriorly xated, anterior sling. The circumferential wrapping of the rectum by synthetic mesh can lead to outlet obstruction. As a result, a modication of this procedure involves securing the mesh to the lateral edges of the rectum.

Historically, this operation was a constipation- inducing operation, making it not suitable for patients with pre-existing constipation problems. It is also associated with signicant morbidity. Aside from constipation and fecal impaction, the major side effects reported are presacral hemorrhage, stricture, small bowel obstruction, impotence, and stula formation. Additionally, the operation is associated with erosion of the anterior portion of the mesh into the bladder. Because of their problems the Ripstein procedure is not commonly employed.

K. Treatment- Resection Rectopexy

The resection rectopexy was rst described in the 1960s by Frykman and Goldberg and still remains the most common treatment option for patients able to tolerate general anesthesia. It is postulated that the resection of the sigmoid colon decreases constipation and possibly lead to lower recurrence. The procedure can be performed in either an open, laparoscopic or robotic method. The surgeon must perform complete mobilization of the rectum to the levator muscles. Second, the rectum is elevated with xation of the rectum to the presacral fascia, usually around the level of S1. The author favors placing two sutures on only one side of the rectum/mesorectum to prevent rectal kinking and obstruction. Last, the surgeon performs a resection of the redundant sigmoid colon with anastomosis. Complications of this procedure include those associated with colonic anastomosis: infection, bleeding, or anastomotic leak. Perioperative events associated with anesthesia are another possibility. Despite the patient population and the anastomosis, the morbidity and mortality is quite low and recurrence rates range between 0 and

2.5% in most series.

L. Suture Rectopexy

Simple abdominal suture rectopexy without resection has also been described. A complete mobilization of the rectum including the lateral stalks is commonly performed and the rectum/mesorectum is sutured or tacked to the sacrum at the S1 level. This procedure can easily be accomplished using minimally invasive techniques such as laparoscopy or robotics. The robotic approach may potentially facilitate the suturing of the rectum to the sacrum. Rectopexy without resection can lead to worsening of preoperatively recognized constipation and should be avoided in these patients. Simple rectopexy is effective for patients without constipation who can tolerate general anesthetic and allows them to avoid the risk and complications of an anastomosis. Most series show a low recurrence rate between 0–5% with low morbidity and mortality.

29 Pelvic Floor Conditions: Rectal Prolapse/Recurrence

M. Treatment- Anterior (Ventral) Rectopexy

The Orr-Loygue (lateral mesh rectopexy) procedure can be considered the rst published account of what is now known as the anterior, or ventral rectopexy. This procedure involved anterior and posterior rectal mobilization to the level of the levator ani muscle, removal of the pouch of Douglas, and suturing of mesh to the lateral rectum on both sides. In 2004, Cleveland Clinic Florida alumnus, Professor Andre D’Hoore of Leuven, Belgium modied the Orr-Loygue technique to include posterior dissection only for exposure of the sacral promontory, no pouch of Douglas excision, and placement of a mesh directly to the ventral aspect of the rectum. This technique suspends the middle and lower rectum yet avoids any constipation- producing lateral dissection. Avoiding posterior and lateral dissection also minimizes nerve injury to the autonomic nerves. Biologic or synthetic mesh has been described but additional studies need to be performed comparing complication and recurrence rates between mesh types. This procedure is technically demanding with dissection and suturing in a tight narrow space. Robotic surgery may potentially facilitate and ease the technical burden.

The procedure begins by incising the peritoneum at the sacral promontory and extending it along the lateral sulcus and across the peritoneal reection. The rectovaginal septum is then dissected all the way down to the anal canal. The placement of an EEA dilator in the vagina can facilitate this part of the dissection. A 20cm long strip of mesh is then cut in the shape of a spatula; with the distal end approximately 4cm wide and the handle end approximately 2 cm wide. The wider distal end is then secured to the anterior wall of the rectum with 6–8 interrupted sutures. The proximal thinner portion of the mesh is secured to the sacrum at the level of S1 with either tacks or suture. Figure29.4 represents the anatomical position of the mesh in the pelvis. The peritoneum is then closed over the mesh. A sacro- colpopexy can easily be done

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Fig. 29.4 Cross-sectional view of ventral rectopexy with mesh. With permission from D’Hoore A. Laparoscopic ventral rectopexy. In: O’Connell R, Madoff R, Solomon M, eds. Operative Surg Colon, Rectum, sixth edn. CRC Press, London, 2015;pp:729–736

at the same time in cases of anterior compartment weakness/prolapse.

Complications known to this procedure include mesh erosions, rectal stricture, rectovaginal stula and dyspareunia. Most published series are mainly in the European literature and are quite promising with low recurrence rates and low morbidity. Faucheron reported on 12 non-randomized case series’ with a total of 574 patients. The recurrence rate was 4.7% with mean followup of 23months. Constipation was improved in 3–72% of patients, while it was worsened in only 0–20%.

N. Results

Studies comparing the different transabdominal approaches to full-thickness rectal prolapse are sparse. Most case series describe one operation and its recurrence rate, morbidity and mortality. These operations all carry fairly low recurrence and morbidity rates while mortality is low. The more interesting aspect of these studies is whether they will remain relevant in an

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C. R. Dwyer and D. C. Maun

increasingly laparoscopic and robotic surgery world.

The laparoscopic approach to fullthickness rectal prolapse has been widely accepted by colorectal surgeons. The recurrence, morbidity and mortality rates are similar to open technique, but laparoscopic technique is associated with shorter hospital stays and faster patient recovery and high levels of patient satisfaction. Robotics has become vogue, especially in the pelvis with urology and gynecology and with the advent of the anterior rectopexy. Suturing in the pelvis with the robot is purportedly easier than during laparoscopy. However, whether this claim translates to improved outcomes remains to be seen.

O. Recurrent Rectal Prolapse

The modern day recurrence rate of techniques for full-thickness rectal prolapse is approximately 10%. In general, the recurrence rate is higher with perineal procedures. Therefore, the colorectal surgeon should be familiar with the diagnosis and treatment of recurrent fullthickness rectal prolapse. A thorough knowledge base on the blood supply of the rectum and distal colon must be understood so that the proper operation can be selected.

The usual diagnostic approach to primary full- thickness rectal prolapse should be repeated in a thorough fashion utilizing data from cinedefecography, physical exam, manometry and history. The surgeon should tease out any constipation or other pelvic oor problems that may have been missed prior to the rst operation. Full informed consent should include a warning that any existing bowel dysfunction may not improve after attempted repair of the recurrence.

The surgeon should know the patient’s prior surgical history and obtain any relevant operative reports. Technique, location of anastomosis, use of mesh, and type of anesthesia are all important to review. Patients who have already undergone a perineal procedure are candidates for repeat perineal procedure or rectopexy (without resection) only. A sigmoid resection in the setting of a previous perineal

anastomosis may cause ischemia to the remaining rectal segment. Similarly, a previous transabdominal resection rectopexy limits the patient to repeat transabdominal procedures only. Perineal procedures, with the exception of the Delorme procedure, should be avoided due to similar concerns for an ischemic segment of bowel. If a patient has only undergone transabdominal rectopexy, then both transabdominal and perineal approaches are available options.

Unfortunately, the results of treatment for recurrent rectal prolapse have not been well dened. Most studies are retrospective and lack any signicant power to draw conclusions regarding the best treatment modality. A recent review of recurrent prolapse highlighted that postoperative results have been described erratically, with some studies completely omitting constipation, incontinence or sexual dysfunction. Additionally, most studies lacked consistent analysis of preoperative bowel function or pelvic oor dysfunction. Larger paired studies with longer follow-up periods are needed to adequately assess the appropriate treatment for recurrent full-thickness rectal prolapse.