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8 Rectal Prolapse andIntussusception
143
further investigate this possible diagnosis include
obstructed defecation, fecal incontinence, tenesmus, pelvic pain, or the endoscopic/histologic
nding of a solitary rectal ulcer (SRUS).
The radiographic nding of rectal intussusception does not itself mandate treatment, as this
can be a nding in otherwise asymptomatic
patients. Patients with rectorectal (low-grade)
intussusception are less likely to experience signicant symptoms than those with rectoanal
(high-grade) intussusception. In either case, initial management in symptomatic patients should
begin with medical management including ber
supplementation, bowel modication and/or biofeedback, or pelvic oor physical therapy.
In patients with refractory symptoms and in
whom appropriate clinical, radiographic and
physiologic testing has been done to isolate rectal
intussusception as the pathologic source of their
symptoms, surgical therapy should be considered. Various surgical procedures, including
mucosal proctectomy (Delorme), stapled transanal rectal resection (STARR) and rectopexy
have been performed with varied success.
The most commonly employed current techniques in the surgical management of rectal
intussusception are the STARR procedure and
laparoscopic ventral rectopexy, and, as noted by
Festen etal. [142], comparative studies between
the two techniques do not exist. Moreover, they
highlight the theory that laparoscopic ventral rectopexy corrects the leading cause of the symptoms (i.e., intussusception), while STARR merely
addresses its consequences.
When observing the healing rate of a solitary
rectal ulcer (SRUS) as the endoscopic manifestation of rectal prolapse, both internal and external,
it has been demonstrated that 70% of patients
will demonstrate healing of the SRUS following
ventral rectopexy, while the remaining patients
will often require posterior STARR for complete
healing and resolution of persistent obstructed
defecation [143]. Due to it’s high rate of complications, the STARR procedure has been mostly
abandoned.
As a stand-alone procedure, laparoscopic ventral rectopexy has shown good efcacy, with
results that rival its use for external rectal prolapse [144]. In a cohort of 100 consecutive female
patients with internal prolapse and rectocele,
laparoscopic ventral rectopexy yielded a cure in
terms of constipation, incontinence and prolapse
symptoms in 79% of patients. Improvements in
constipation (92%) and incontinence (86%) alone
were more profound [145].
Conclusions
In summary, rectal prolapse is a pelvic oor
disorder, which causes severe compromise in
quality of life. Although many variations have
been described in surgical management, the
most common approach is an abdominal rectopexy for most patients and a perineal
approach in patients who are too frail to permit an abdominal approach. The abdominal
operations are generally preferred with some
minimally invasive method. Rectal intussusception is a rare condition, often diagnosed
during defecography, which is generally medically managed.
References
1. Bordeianou L, Hicks CW, Kaiser AM, Alavi K,
Sudan R, Wise PE. Rectal prolapse: an overview
of clinical features, diagnosis, and patient-specic management strategies. J Gastrointest Surg.
2014;18:1059–69.
2. Michalopoulos A, Papadopoulos VN, Panidis S,
etal. Surgical management of rectal prolapse. Tech
Coloproctol. 2011;15(Suppl 1):S25–8.
3. 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.
4. Steele SR, Varma MG, Prichard D, et al. The evolution of evaluation and management of urinary or
fecal incontinence and pelvic organ prolapse. Curr
Probl Surg. 2015;52:17–75. 92–136.
5. Madoff RD, Mellgren A. One hundred years
of rectal prolapse surgery. Dis Colon Rectum.
1999;42:441–50.
6. Brown AJ, Anderson JH, McKee RF, Finlay
IG. Strategy for selection of type of operation for
rectal prolapse based on clinical criteria. Dis Colon
Rectum. 2004;47:103–7.
7. Varma M, Rafferty J, Buie WD, Standards Practice
Task Force of American Society of C, Rectal
144
J. R. Snyder and I. M. Paquette
S.Practice parameters for the management of rectal
prolapse. Dis Colon Rectum. 2011;54:1339–46.
8. Hayden DM, Wexner SD. Rectal prolapse: current
evaluation, management and treatment of a historically recurring disorder. In: Steele S, Maykel J,
Champagne B, Orangio G, editors. Complexities in
colorectal surgery: decision-making and management. NewYork: Springer; 2014. p.173–83.
9. Raftopoulos Y, Senagore AJ, Di Giuro G,
Bergamaschi R, Rectal Prolapse Recurrence Study
G. 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.
10. Russell MM, Read TE, Roberts PL, et al.
Complications after rectal prolapse surgery: does
approach matter? Dis Colon Rectum. 2012;55:450–8.
11. Senapati A, Gray RG, Middleton LJ, etal. PROSPER:
a randomised comparison of surgical treatments for
rectal prolapse. Color Dis. 2013;15:858–68.
12. Barak M, Peted E. Anesthesia and peri-operative
care of the elderly patient. Harefuah. 2011;150:153–
7. 204.
13. Steinmetz J, Rasmussen LS.The elderly and general
anesthesia. Minerva Anestesiol. 2010;76:745–52.
14. Halaszynski TM. Pain management in the elderly
and cognitively impaired patient: the role of regional
anesthesia and analgesia. Curr Opin Anaesthesiol.
2009;22:594–9.
15. Liu LL, Wiener-Kronish JP.Perioperative anesthesia
issues in the elderly. Crit Care Clin. 2003;19:641–56.
16. 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.
17. Bibi S, Zutshi M, Gurland B, Hull T.Rectal prolapse
in octogenarians: does surgery impact daily activity?
Am Surg. 2015;81:371–2.
18. Germain A, Perrenot C, Scherrer ML, etal. Longterm outcome of robotic-assisted laparoscopic rectopexy for full-thickness rectal prolapse in elderly
patients. Color Dis. 2014;16:198–202.
19. Laubert T, Bader FG, Kleemann M, etal. Outcome
analysis of elderly patients undergoing laparoscopic
resection rectopexy for rectal prolapse. Int J Color
Dis. 2012;27:789–95.
20. Lee SH, Lakhtaria P, Canedo J, Lee YS, Wexner
SD. Outcome of laparoscopic rectopexy versus
perineal rectosigmoidectomy for full-thickness
rectal prolapse in elderly patients. Surg Endosc.
2011;25:2699–702.
21. Speakman CT, 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;78:1431–3.
22. Madiba TE, Baig MK, Wexner SD.Surgical management of rectal prolapse. Arch Surg. 2005;140:63–73.
23. Bachoo P, Brazzelli M, Grant A. Surgery for complete rectal prolapse in adults. Cochrane Database
Syst Rev. 2000;2:CD001758.
24. Bishawi M, Foppa C, Tou S, Bergamaschi R, Rectal
Prolapse Recurrence Study G.Recurrence of rectal
prolapse following rectopexy: a pooled analysis of
532 patients. Color Dis. 2016;18:779–84.
25. Loygue J. Surgical treatment of complete prolapse
of the rectum by promontory rectopexy. Scalpel
(Brux). 1965;118:1081–7.
26. Carter AE. Rectosacral suture xation for complete rectal prolapse in the elderly, the frail and the
demented. Br J Surg. 1983;70:522–3.
27. Blatchford GJ, Perry RE, Thorson AG, Christensen
MA. Rectopexy without resection for rectal prolapse. Am J Surg. 1989;158:574–6.
28. 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;81:904–6.
29. Khanna AK, Misra MK, Kumar K. Simplied
sutured sacral rectopexy for complete rectal prolapse
in adults. Eur J Surg. 1996;162:143–6.
30. Briel JW, Schouten WR, Boerma MO. Long-term
results of suture rectopexy in patients with fecal
incontinence associated with incomplete rectal prolapse. Dis Colon Rectum. 1997;40:1228–32.
31. 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.
32. Aitola PT, Hiltunen KM, Matikainen MJ.Functional
results of operative treatment of rectal prolapse over
an 11-year period: emphasis on transabdominal
approach. Dis Colon Rectum. 1999;42:655–60.
33. Nunoo-Mensah JW, Efron JE, Young-Fadok
TM. Laparoscopic rectopexy. Surg Endosc.
2007;21:325–6.
34. Berman IR. Sutureless laparoscopic rectopexy for
procidentia. Technique and implications. Dis Colon
Rectum. 1992;35:689–93.
35. Foppa C, Martinek L, Arnaud JP, Bergamaschi
R.Ten-year follow up after laparoscopic suture rectopexy for full-thickness rectal prolapse. Color Dis.
2014;16:809–14.
36. Kariv Y, Delaney CP, Casillas S, etal. Long-term
outcome after laparoscopic and open surgery for
rectal prolapse: a case-control study. Surg Endosc.
2006;20:35–42.
37. Wilson J, Engledow A, Crosbie J, Arulampalam
T, Motson R. Laparoscopic nonresectional suture
rectopexy in the management of full-thickness rectal prolapse: substantive retrospective series. Surg
Endosc. 2011;25:1062–4.
38. Sahoo MR, Thimmegowda AK, Gowda MS.A single centre comparative study of laparoscopic mesh
rectopexy versus suture rectopexy. J Minim Access
Surg. 2014;10:18–22.
39. Kessler H, Jerby BL, Milsom JW. Successful treatment of rectal prolapse by laparoscopic suture rectopexy. Surg Endosc. 1999;13:858–61.
40. Heah SM, Hartley JE, Hurley J, Duthie GS, Monson
JR.Laparoscopic suture rectopexy without resection
is effective treatment for full-thickness rectal prolapse. Dis Colon Rectum. 2000;43:638–43.
8 Rectal Prolapse andIntussusception
145
41. Boccasanta P, Rosati R, Venturi M, etal. Comparison
of laparoscopic rectopexy with open technique in
the treatment of complete rectal prolapse: clinical and functional results. Surg Laparosc Endosc.
1998;8:460–5.
42. Solomon MJ, Young CJ, Eyers AA, Roberts
RA.Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse. Br
J Surg. 2002;89:35–9.
43. Tou S, Brown SR, Nelson RL.Surgery for complete
(full-thickness) rectal prolapse in adults. Cochrane
Database Syst Rev. 2015;11:CD001758.
44. Byrne CM, Smith SR, Solomon MJ, Young JM,
Eyers AA, Young CJ. Long-term functional outcomes after laparoscopic and open rectopexy for
the treatment of rectal prolapse. Dis Colon Rectum.
2008;51:1597–604.
45. Purkayastha S, Tekkis P, Athanasiou T, et al. A
comparison of open vs. laparoscopic abdominal
rectopexy for full-thickness rectal prolapse: a metaanalysis. Dis Colon Rectum. 2005;48:1930–40.
46. Ripstein CB. Procidentia: denitive corrective surgery. Dis Colon Rectum. 1972;15:334–6.
47. Gordon PH, Hoexter B.Complications of the Ripstein
procedure. Dis Colon Rectum. 1978;21:277–80.
48. Dyrberg DL, Nordentoft T, Rosenstock
S. Laparoscopic posterior mesh rectopexy for rectal prolapse is a safe procedure in older patients:
a prospective follow-up study. Scand J Surg.
2015;104:227–32.
49. 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.
50. 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.
51. Kupfer CA, Goligher JC.One hundred consecutive
cases of complete prolapse of the rectum treated by
operation. Br J Surg. 1970;57:482–7.
52. Roberts PL, Schoetz DJ Jr, Coller JA, Veidenheimer
MC. Ripstein procedure. Lahey Clinic experience:
1963-1985. Arch Surg. 1988;123:554–7.
53. McMahan JD, Ripstein CB. Rectal prolapse. An
update on the rectal sling procedure. Am Surg.
1987;53:37–40.
54. Wells C.New operation for rectal prolapse. Proc R
Soc Med. 1959;52:602–3.
55. Madbouly KM, Senagore AJ, Delaney CP, Duepree
HJ, Brady KM, Fazio VW. Clinically based
management of rectal prolapse. Surg Endosc.
2003;17:99–103.
56. Winde G, Reers B, Nottberg H, Berns T, Meyer J,
Bunte H.Clinical and functional results of abdominal rectopexy with absorbable mesh-graft for
treatment of complete rectal prolapse. Eur J Surg.
1993;159:301–5.
57. 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.
58. 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.
59. Wong M, Meurette G, Abet E, Podevin J, Lehur
PA. Safety and efcacy of laparoscopic ventral
mesh rectopexy for complex rectocele. Color Dis.
2011;13:1019–23.
60. Maggiori L, Bretagnol F, Ferron M, Panis
Y. Laparoscopic ventral rectopexy: a prospective
long-term evaluation of functional results and quality of life. Tech Coloproctol. 2013;17:431–6.
61. 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.
62. Consten EC, van Iersel JJ, Verheijen PM, Broeders
IA, Wolthuis AM, D'Hoore A. Long-term outcome
after laparoscopic ventral mesh rectopexy: an observational study of 919 consecutive patients. Ann
Surg. 2015;262:742–8.
63. Randall J, Smyth E, McCarthy K, Dixon
AR. Outcome of laparoscopic ventral mesh rectopexy for external rectal prolapse. Color Dis.
2014;16:914–9.
64. 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.
65. 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.
66. Sileri P, Franceschilli L, de Luca E, et al.
Laparoscopic ventral rectopexy for internal rectal
prolapse using biological mesh: postoperative and
short-term functional results. J Gastrointest Surg.
2012;16:622–8.
67. Bloemendaal AL, Mishra A, Nicholson GA,
et al. Laparoscopic rectopexy is feasible and safe
in the emergency admission setting. Color Dis.
2015;17:O198–201.
68. Owais AE, Sumrien H, Mabey K, McCarthy K,
Greenslade GL, Dixon AR. Laparoscopic ventral
mesh rectopexy in male patients with internal or external rectal prolapse. Color Dis. 2014;16:995–1000.
69. Faucheron JL, Trilling B, Girard E, Sage PY, Barbois
S, Reche F.Anterior rectopexy for full-thickness rectal prolapse: technical and functional results. World J
Gastroenterol. 2015;21:5049–55.
70. Formijne Jonkers HA, Maya A, Draaisma WA, etal.
Laparoscopic resection rectopexy versus laparoscopic ventral rectopexy for complete rectal prolapse. Tech Coloproctol. 2014;18:641–6.
71. 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.
72. Ogilvie JW Jr, Stevenson AR, Powar M. Casematched series of a non-cross-linked biologic versus
non-absorbable mesh in laparoscopic ventral rectopexy. Int J Color Dis. 2014;29:1477–83.
146
J. R. Snyder and I. M. Paquette
73. Wahed S, Ahmad M, Mohiuddin K, Katory M,
Mercer-Jones M.Short-term results for laparoscopic
ventral rectopexy using biological mesh for pelvic
organ prolapse. Color Dis. 2012;14:1242–7.
74. Frykman HM. Abdominal proctopexy and primary
sigmoid resection for rectal procidentia. Am J Surg.
1955;90:780–9.
75. Frykman HM, Goldberg SM. The surgical treatment of rectal procidentia. Surg Gynecol Obstet.
1969;129:1225–30.
76. Delaney CP. Laparoscopic management of rectal
prolapse. J Gastrointest Surg. 2007;11:150–2.
77. Schultz I, Mellgren A, Oberg M, Dolk A, Holmstrom
B.Whole gut transit is prolonged after Ripstein rectopexy. Eur J Surg. 1999;165:242–7.
78. 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.
79. Ashari LH, Lumley JW, Stevenson AR, Stitz
RW. Laparoscopically-assisted resection rectopexy
for rectal prolapse: ten years’ experience. Dis Colon
Rectum. 2005;48:982–7.
80. Watts AM, Thompson MR.Evaluation of Delorme’s
procedure as a treatment for full-thickness rectal
prolapse. Br J Surg. 2000;87:218–22.
81. Husa A, Sainio P, von Smitten K. Abdominal rectopexy and sigmoid resection (Frykman-Goldberg
operation) for rectal prolapse. Acta Chir Scand.
1988;154:221–4.
82. Huber FT, Stein H, Siewert JR. Functional results
after treatment of rectal prolapse with rectopexy and
sigmoid resection. World J Surg. 1995;19:138–43.
discussion 143.
83. Luukkonen P, Mikkonen U, Jarvinen H.Abdominal
rectopexy with sigmoidectomy vs. rectopexy alone
for rectal prolapse: a prospective, randomized study.
Int J Color Dis. 1992;7:219–22.
84. Sayfan J, Pinho M, Alexander-Williams J, Keighley
MR. Sutured posterior abdominal rectopexy with
sigmoidectomy compared with Marlex rectopexy
for rectal prolapse. Br J Surg. 1990;77:143–5.
85. Agachan F, Reissman P, Pfeifer J, Weiss EG,
Nogueras JJ, Wexner SD.Comparison of three perineal procedures for the treatment of rectal prolapse.
South Med J. 1997;90(9):925–32.
86. Elagili F, Gurland B, Liu X, Church J, Ozuner
G. Comparing perineal repairs for rectal prolapse:
Delorme versus Altemeier. Tech Coloproctol.
2015;19:521–5.
87. Altemeier WA, Culbertson WR, Schowengerdt C,
Hunt J. Nineteen years’ experience with the onestage perineal repair of rectal prolapse. Ann Surg.
1971;173:993–1006.
88. Altemeier WA, Culbertson WR, Alexander JW.Onestage perineal repair of rectal prolapse. Twelve
years’ experience. Arch Surg. 1964;89:6–16.
89. Altemeier WA, Giusef J, Hoxworth P.Treatment of
extensive prolapse of the rectum in aged or debilitated patients. AMA Arch Surg. 1952;65:72–80.
90. Towliat SM, Mehrvarz S, Mohebbi HA, Sate Bigdeli
A.Outcomes of rectal prolapse using the Altemeier
procedure. Iran Red Crescent Med J. 2013;15:620–1.
91. Kimmins MH, Evetts BK, Isler J, Billingham R.The
Altemeier repair: outpatient treatment of rectal prolapse. Dis Colon Rectum. 2001;44:565–70.
92. Gravante G, Venditti D. The Altemeier procedure:
new technologies for an old technique. Dis Colon
Rectum. 2006;49:1801–2.
93. Gramkow CS, Lanng C, Fischer A.Altemeier repair
of rectal prolapse. Ugeskr Laeger. 2005;167:286–9.
94. Gopal KA, Amshel AL, Shonberg IL, Eftaiha
M. Rectal procidentia in elderly and debilitated
patients. Experience with the Altemeier procedure.
Dis Colon Rectum. 1984;27:376–81.
95. Cirocco WC.The Altemeier procedure for rectal prolapse: an operation for all ages. Dis Colon Rectum.
2010;53:1618–23.
96. Bennett BH, Geelhoed GW. A stapler modication of the Altemeier procedure for rectal prolapse.
Experimental and clinical evaluation. Am Surg.
1985;51:116–20.
97. Carditello A, Milone A, Stilo F, Mollo F, Basile
M.Surgical treatment of rectal prolapse with transanal resection according to Altemeier. Experience
and results. Chir Ital. 2003;55:687–92.
98. 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.
99. Steele SR, Goetz LH, Minami S, Madoff RD,
Mellgren AF, Parker SC. Management of recurrent
rectal prolapse: surgical approach inuences outcome. Dis Colon Rectum. 2006;49:440–5.
100. Chun SW, Pikarsky AJ, You SY, etal. Perineal rectosigmoidectomy for rectal prolapse: role of levatorplasty. Tech Coloproctol. 2004;8:3–8. discussion
8–9.
101. Habr-Gama A, Jacob CE, Jorge JM, et al. Rectal
procidentia treatment by perineal rectosigmoidectomy combined with levator ani repair. HepatoGastroenterology. 2006;53:213–7.
102. 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.
103. Baig MK, Galliano D, Larach JA, Weiss EG,
Wexner SD, Nogueras JJ. Pouch perineal rectosigmoidectomy: a case report. Surg Innov.
2005;12(4):373–5.
104. Yoshioka K1, Ogunbiyi OA, Keighley MR. Pouch
perineal rectosigmoidectomy gives better functional results than conventional rectosigmoidectomy
in elderly patients with rectal prolapse. Br J Surg.
1998;85(11):1525–6.
105. Cirocco WC.Explaining the undulating outcomes of
perineal rectosigmoidectomy (Altemeier procedure)
for rectal prolapse over the last century: technique
matters! Tech Coloproctol. 2014;18:979–80.
8 Rectal Prolapse andIntussusception
147
106. 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.
107. Lechaux JP, Johann M.Delorme’s operation in the treatment of rectal prolapse. Presse Med. 1984;13:219–20.
108. Lieberth M, Kondylis LA, Reilly JC, Kondylis
PD. The Delorme repair for full-thickness rectal prolapse: a retrospective review. Am J Surg.
2009;197:418–23.
109. Marchal F, Bresler L, Ayav A, et al. Long-term
results of Delorme’s procedure and Orr-Loygue rectopexy to treat complete rectal prolapse. Dis Colon
Rectum. 2005;48:1785–90.
110. Watkins BP, Landercasper J, Belzer GE, etal. Longterm follow-up of the modied Delorme procedure
for rectal prolapse. Arch Surg. 2003;138:498–502.
discussion 502–493.
111. Tobin SA, Scott IH. Delorme operation for rectal
prolapse. Br J Surg. 1994;81:1681–4.
112. Pescatori M, Interisano A, Stol VM, Zoffoli
M. Delorme’s operation and sphincteroplasty for
rectal prolapse and fecal incontinence. Int J Color
Dis. 1998;13:223–7.
113. Chen CW, Zhang G, Yan CH, Wang CF. Delorme
procedure for full-thickness rectal prolapse: a report
of 25 cases. Zhonghua Wei Chang Wai Ke Za Zhi.
2012;15(3):285–7.
114. Parikh V.Re: The Delorme procedure: a useful operation for complicated rectal prolapse in the elderly.
Am Surg. 1997;63:845.
115. Milito G, Cadeddu F, Selvaggio I, Grande
M. The Delorme repair for full-thickness rectal prolapse: a retrospective review. Am J Surg.
2010;199:581–2.
116. Liberman H, Hughes C, Dippolito A. Evaluation
and outcome of the Delorme procedure in the treatment of rectal outlet obstruction. Dis Colon Rectum.
2000;43:188–92.
117. Kling KM, Rongione AJ, Evans B, McFadden
DW.The Delorme procedure: a useful operation for
complicated rectal prolapse in the elderly. Am Surg.
1996;62:857–60.
118. Houry S. Delorme procedure for rectal prolapse. J
Chir (Paris). 2000;137:338–41.
119. De Nardi P, Osman N, Viola M, Staudacher
C. Ischemic proctitis following Delorme procedure for external rectal prolapse. Tech Coloproctol.
2006;10:253–5.
120. Turell R.The Thiersch operation for rectal prolapse and
anal incontinence. N Y State J Med. 1954;54:791–5.
121. Gabriel WB.The Thiersch operation for rectal prolapse. Dis Colon Rectum. 1964;7:383–5.
122. Poole GV Jr, Pennell TC, Myers RT, Hightower
F. Modied Thiersch operation for rectal prolapse.
Technique and results. Am Surg. 1985;51:226–9.
123. Terrell RV. Experience with Thiersch wire in rectal
prolapse. AORN J. 1968;8:72–6.
124. Abe T, Hachiro Y, Kunimoto M. Combined aluminum potassium sulfate and tannic acid sclerosing
therapy and anal encirclement using an elastic articial ligament for rectal prolapse. Dis Colon Rectum.
2014;57:653–7.
125. Burke RM, Jackman RJ.A modied Thiersch operation in treatment of complete rectal prolapse. Dis
Colon Rectum. 1959;2:555–61.
126. Haskell B, Rovner H.A modied Thiersch operation
for complete rectal prolapse using a Teon prosthesis. Dis Colon Rectum. 1963;6:192–5.
127. Khanduja KS, Hardy TG Jr, Aguilar PS, etal. A new
silicone-prosthesis in the modied Thiersch operation. Dis Colon Rectum. 1988;31:380–3.
128. Larach SW, Vazquez B. Modied Thiersch procedure with silastic mesh implant: a simple solution for
fecal incontinence and severe prolapse. South Med J.
1986;79:307–9.
129. Sainio AP, Halme LE, Husa AI. Anal encirclement with polypropylene mesh for rectal prolapse and incontinence. Dis Colon Rectum.
1991;34:905–8.
130. Schwartz A, Marin R. Use of polyethylene in
the Thiersch operation. Dis Colon Rectum.
1962;5:302–5.
131. Stimpel H, Pedersen T.A modied Thiersch surgical
method with polypropylene gauze (Marlex) in rectal
prolapse. Ugeskr Laeger. 1988;150:1471–3.
132. Swerdlow H. The Encircler. A new instrument
for the performance of the Thiersch procedure for rectal procidentia. Dis Colon Rectum.
1986;29:145–7.
133. Thorlakson RH.A modication of the Thiersch procedure for rectal prolapse using polyester tape. Dis
Colon Rectum. 1982;25:57–8.
134. Zutshi M, Hull T, Gurland B. Anal encirclement
with sphincter repair (AESR procedure) using a biological graft for anal sphincter damage involving the
entire circumference. Color Dis. 2012;14:592–5.
135. Earnshaw JJ, Hopkinson BR.Late results of silicone
rubber perianal suture for rectal prolapse. Dis Colon
Rectum. 1987;30:86–8.
136. Hunt TM, Fraser IA, Maybury NK. Treatment of
rectal prolapse by sphincteric support using silastic
rods. Br J Surg. 1985;72:491–2.
137. Jackaman FR, Francis JN, Hopkinson BR.Silicone
rubber band treatment of rectal prolapse. Ann R Coll
Surg Engl. 1980;62:386–7.
138. Vongsangnak V, Varma JS, Smith AN. Reappraisal
of Thiersch’s operation for complete rectal prolapse.
J R Coll Surg Edinb. 1985;30:185–7.
139. Calata JF, Pai A, Marecik S, Prasad LM, Park
JJ. Perineal proctectomy with bio-Thiersch procedure for complete rectal prolapse with fecal incontinence. Dis Colon Rectum. 2015;58:e45.
140. Hool GR, Hull TL, Fazio VW. Surgical treatment
of recurrent complete rectal prolapse: a thirty-year
experience. Dis Colon Rectum. 1997;40:270–2.
141. 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.
148
J. R. Snyder and I. M. Paquette
142. Festen S, van Geloven AA, D'Hoore A, Lindsey
I, Gerhards MF. Controversy in the treatment of
symptomatic internal rectal prolapse: suspension or
resection? Surg Endosc. 2011;25:2000–3.
143. Evans C, Ong E, Jones OM, Cunningham C, Lindsey
I. Laparoscopic ventral rectopexy is effective for
solitary rectal ulcer syndrome when associated with
rectal prolapse. Color Dis. 2014;16:O112–6.
144. Gosselink MP, Joshi H, Adusumilli S, etal. Laparoscopic ventral rectopexy for faecal incontinence:
equivalent benet is seen in internal and external rectal prolapse. J Gastrointest Surg. 2015;19:
558–63.
145. Franceschilli L, Varvaras D, Capuano I, et al.
Laparoscopic ventral rectopexy using biologic
mesh for the treatment of obstructed defaecation
syndrome and/or faecal incontinence in patients
with internal rectal prolapse: a critical appraisal
of the rst 100 cases. Tech Coloproctol. 2015;19:
209–19.
Fecal Incontinence
JuliaSaraidaridis andLilianaBordeianou
9
Introduction
Fecal Incontinence (FI) is dened as the involuntary loss of feces or gas in a person who has
already gained continence [1]. There is a prevalence range for FI quoted in the literature (0.4–
19.6%); with the variety in estimation thought
to be due to heterogeneity of study design, differing denitions of FI, and patient reluctance to
report symptoms. A recent meta-analysis quoted
FI to affect 5.9% of the population [2]. The largest household study in the United States reported
an incidence of 18.8% [3]. Factors that increase
the likelihood of reporting fecal incontinence
include increasing age and institutionalized status. In fact, a US survey of patients in nursing
homes estimated around 47% of residents suffered from FI.They also detailed that this was
one of the main reasons for transition to such a
living arrangement [4]. Overall, FI is a common
disorder in the population with signicant social
stigma associated with it. Fortunately, in many
instances, the symptoms can be improved and
J. Saraidaridis
Division of Colon and Rectal Surgery, Lahey Clinic,
Burlington, MA, USA
L. Bordeianou (*)
Department of General Surgery, Pelvic Floor
Disorders Center, Massachusetts General Hospital,
Boston, MA, USA
e-mail: lbordeianou@partners.org
potentially even cured. Unfortunately, less than
one third of women with FI discuss the problem
with a physician. In a study by Brown et al.,
both the duration and severity of incontinence
correlated with likelihood to seek care for the
condition [5]. While there is no quick x for
fecal incontinence, patients and physicians
working together can improve and potentially
cure fecal incontinence and vastly improve
patient quality of life.
Normal Continence
The maintenance of fecal continence requires a
complex interplay of factors. Anatomically, the
internal anal sphincter is a continuation of the
smooth muscle layer of the rectum. This muscle
thickens as it reaches the anal verge and is under
continuous, tonic contraction that maintains
approximately 75% of resting continence.
However, during times of rectal distension, the
internal anal sphincter will momentarily relax to
allow for sampling of the rectal contents by the
sensory nerves of the transition zone. This reex
is called the recto-anal inhibitory reex or RAIR.
The external anal sphincter and puborectalis are
skeletal muscle under voluntary control and have
somatic innervation via the pudendal nerve and
S3–S4 sacral nerves, respectively. These muscles
are also tonically contracted, but can increase
their contraction force to more than double as
© Springer International Publishing AG, part of Springer Nature 2019
D. E. Beck et al. (eds.), Fundamentals of Anorectal Surgery,
https://doi.org/10.1007/978-3-319-65966-4_9
149
150
J. Saraidaridis and L. Bordeianou
needed. There is a spinal reex that prompts
external anal sphincter contraction during sudden
increases in intra-abdominal pressure (such as a
cough). During the process of normal defecation,
a patient must relax both the external anal sphincter and the puborectalis to allow straightening of
the anorectal canal [6]. The maintenance of
continence requires an intact mental status, normal anorectal sensation, sphincter complex function, rectal compliance, and normal stool
consistency. Therefore there are a variety of ways
in which continence can be disrupted [7].
Evaluation
When a patient rst presents with fecal incontinence, a thorough history and physical examination are integral to understanding their condition.
Efforts should be made to quantify and qualify the
episodes of fecal incontinence. The severity of FI
should be quantied using a validated scoring
system. Although multiple graded, weighted, and
unweighted scoring systems have been described
in the literature [8], the most commonly employed
method is the Cleveland Clinic Florida Fecal
Incontinence Score (CCF-FIS) [9]. In addition,
questionnaires like the Fecal Incontinence
Severity Index (FISI) and Fecal Incontinence
Quality of Life Scale (FIQoL) scale can be helpful to provide a standardized way of assessing a
patient’s FI.These questionnaires were developed
in 1999 and 2000 and the FIQoL has been adopted
by the American Society of Colon and Rectal
Surgeons (ASCRS) as that society’s tool to assess
FI’s effect on quality of life [10, 11]. The utility of
these validated measures in assessing a patient’s
severity of FI and its effect on quality of life has
caused them to be recommended by the ASCRS
as a valuable tool in diagnosing and treating FI
[12]. However, because they are more cumber-
some to use than the scoring systems, they are not
as widely employed clinically and are used primarily as a research tool. Moreover, they highlight the discrepancy between the views of
patients and surgeons. During the clinic interview,
clinicians should assess for medically or surgically treatable etiologies of fecal incontinence.
The history should always include an inquiry into
a previous history of sphincter trauma either
through previous obstetric injury such as forceps
delivery or episiotomy or through previous anorectal surgery including stulotomy, hemorrhoidectomy, lateral internal sphincterotomy, or low
anterior resection. Denervation of the pudendal
nerve due to prolonged childbirth, chronic rectal
prolapse, or neurologic conditions like spina
bida, myelomeningocele, or multiple sclerosis
can also contribute to fecal incontinence.
Additionally, any patient with reduced compliance of the rectum from ulcerative colitis or radiation proctitis will have difculty controlling their
continence. Finally, any patients with poorly controlled diarrhea due to inammatory bowel disease, lactose intolerance, or bile salt malabsorption
can appear as if they have fecal incontinence. All
of these risk factors are important to assess in the
initial interview as some can be treated with medical or behavioral modications and some may
benet from surgical intervention.
Physical examination should include inspection of the perineal body to assess for thinning
of the tissue or scarring from previous trauma
or interventions. Fistulae, prolapse, or a patulous anus will often be obvious on inspection
as well. Some patients will require a Valsalva
maneuver to demonstrate rectal prolapse. A
digital rectal exam, assessing for mass, resting sphincter tone, and maximum sphincter
squeeze will provide good information as well.
An internal exam will also rule out fecal impaction, which can cause overow incontinence
and should be treated by other treatment paradigms. Finally, if the patient has any concern
for malignancy or mass, a exible sigmoidoscopy may be required (either in the ofce or set
up for a later date).
Following a thorough history and physical
examination, the physician should have a working idea of the source of fecal incontinence. For
all patients, regardless of the etiology of their FI,
a trial of medical therapy inclusive of ber supplementation and/or anti-diarrheal medications,
biofeedback, and lifestyle modication is indicated. If symptoms are still severe after an adequate attempt at medical therapy, further efforts
9 Fecal Incontinence
Fig. 9.1 Endoanal
ultrasonography
demonstrates a classic
disruption in the external
anal sphincter and
internal anal sphincter
anteriorly, with internal
sphincter retraction and
a thinned perineal body
(4mm)
151
at evaluation are merited, and the patient should
undergo a pelvic oor evaluation.
The two studies that provide potentially useful
diagnostic information are: anal endosonography
and anal manometry. The rst test to evaluate the
pelvic oor is anal endosonography to assess for
sphincter integrity. Anal endosonography is performed by using a two-dimensional ultrasound
scanner with a rotating probe allowing for a
circumferential view of the anal canal (Fig.9.1).
This probe is then inserted into the rectal cavity
and slowly withdrawn allowing for cross-sectional
imaging of the musculature of the pelvic oor.
Anal endosonography allows the evaluation of
muscular defects in the sphincter complex, which
are surgically amenable to repair. There may be
utility in performing anal endosonography to
discover occult injuries in patients without overt
injuries on physical exam. In one study examining
post-partum patients without a clinically obvious
tear, 28% had an anal injury that could be identied by anal endosonography. These patients were
subsequently 8.8-times more likely to develop
fecal incontinence in 3months in comparison to
their compatriots without an occult injury [13].
While the presence of a sphincter defect on ultrasound is not adequate information to move forward with surgical intervention, the presence of
a defect is associated with symptoms of FI and
decreased continence [13].
While anal endosonography aids in evaluating
the anatomy of the pelvic oor, anal manometry
can help elucidate the function of the pelvic oor.
Anal manometry is performed by inserting a thin
exible catheter attached to a pressure transducer
into the patient’s rectum. Resting and squeeze
pressures are obtained at different points along
the rectum. Maximum resting pressure is dened
as the highest measurement obtained with the
patient at rest (range: 40–80mmHg). Maximum
squeeze pressure is dened as the difference
between squeeze pressure and baseline pressure. Rectal compliance is assessed by lling an
intra-rectal balloon with the volume that causes
an intolerable sensation of distension. Actual
values of maximum resting pressure <40mmHg,
a maximal squeeze pressure <60 mmHg, and
a rectal capacitance <200 mL in women are
thought to be seen primarily with incontinence
[14, 15]. In comparison to patients who are continent, patients with fecal incontinence have
signicantly lower maximum resting pressure,
maximal squeeze pressure, and decreased rectal
capacitance. However, there is signicant overlap between groups and the severity of FI is not
associated with the severity of anal manometric
derangement [16]. Despite these misgivings, the
information from anal manometry is helpful to
the clinician. While it does not provide the diagnosis of fecal incontinence or rate its severity,
152
J. Saraidaridis and L. Bordeianou
anal manometry does provide useful information
for potential intervention in the disorder.
Previously, pudendal nerve terminal motor
latency (PNTML) was thought to be an important aspect of pelvic oor testing for fecal
incontinence. The inclusion of this test in the
evaluation of fecal incontinence stemmed from
the belief that pudendal neuropathy due to childbirth, repeated straining, or neurologic disorders
was one of the common etiologies of FI.While
pudendal neuropathy is present in up to 70% of
patients with FI, it’s presence makes little difference to the patient or clinician. Some studies have
shown that patients with prolonged PNTML do
not benet from sphincteroplasty [17], however,
this claim has been contested in other studies.
Treatment
Conservative Management
As stated earlier, medical management is the
rst-line therapy for patients with fecal incontinence. Medical management is a multi-faceted
approach that aims at ameliorating FI symptoms
and controlling any underlying medical problem
that results in loose, frequent stools. Conditions
such as inammatory bowel disease, hyperthyroidism, and celiac disease should be identied
and treated to minimize their contribution to
FI.After tight control of co-existing medical conditions, medical management should follow a
multi-pronged approach including ber supplementation, anti-diarrheals, behavior modication, and biofeedback.
The addition of ber, anti-diarrheals, or amitriptyline to a patient’s regimen can result in
signicant improvement in FI. Soluble (psyllium ber) is thought to both bulk the stool and
cause a gel to form within the stool improving consistency to obtain continence. A study
evaluating the best type of ber to supplement
in patients with FI found that psyllium reduced
the incidence of FI to 2.5 episodes per week in
comparison to 4.3 with gum arabic, 6.2 with
carboxymethylcellulose, and 5.5in the placebo
arm [18]. Anti-diarrheals such as loperamide
and diphenoxylate-atropine are medications
that can be used to improve symptoms of
fecal incontinence by reducing diarrhea. Their
method of action is to decrease intestinal motility and slow transit causing a more formed stool
to occur. The Fecal Incontinence Prescription
Management (FIRM) randomized clinical trial
showed equal ability of loperamide and ber
supplementation to benet episodes of FI in
patients who had at least one episode of FI during a 1-week bowel habit diary. Those using
ber had less incidence of constipation [19].
Finally, the tri-cyclic anti-depressant, amitriptyline, has been identied as another potential
benecial medication for those with FI. In a
small study in 18 individuals with FI, amitriptyline improved FI scores, decreased the number
of daily BMs, and decreased the frequency and
amplitude of rectal motor complexes. Overall
this medication improved the symptoms of FI
in 89% of the patients. The mechanism of action
of amitriptyline is thought to be the decrease in
amplitude and frequency of rectal motor complexes and the simultaneous increase in colonic
transit time [20]. While there is much work to
be done on further options for medical treatment
for FI, psyllium, anti-diarrrheals, and amitriptyline are good initial options.
Patients are asked to keep a food and symptom diary to aid in identifying potential triggers
to incontinence episodes. In particular, patients
are asked to keep careful attention to the ingestion of alcohol, fatty foods, caffeine, lactose,
and articial sweeteners as, historically, these
items have been known to promote loose stools
and episodes of FI [21]. Supportive measures
include efforts at optimizing skin care and perineal hygiene including the use of protective
ointments, gentle soaps, deodorants, and absorbent pads. Taken in concert, all of these efforts
together often have signicant improvement on
patients’ quality of life.
Another aspect of conservative management
of FI is the use of biofeedback or pelvic oor
rehabilitation. This is a noninvasive therapy that
uses electronic or mechanical devices to improve
coordination and strength of the sphincter complex. Biofeedback starts with a patient perform-