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Ga
rcea G, Sutton CD, Lloyd TD, et al. Management of benign rectal stric-
tures: a review of present therapeutic procedures. Dis Colon Rectum.
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Gumaste V, Sachar DB, Greenstein AJ. Benign and malignant colorectal stric-
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RECTAL AND PARARECTAL REGION
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tomotic strictures. Dis Colon Rectum. 2001;44(10):1464.
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tive colorectal anastomotic strictures. Surg Endosc. 2003;17(7):1110–1113.
. En
doscopic placement of self-
101
F
M
I
Sergio Larach and Beatriz Mar
INTR
ODUCTION
F
ecal impaction may be dened as a large compacted mass of feces
(fecaloma) that becomes stuck in the colon or rectum and cannot be
evacuated by the patient. Fecal impaction is common and causes signicant morbidity. Although it can occur at all ages, some groups of
patients are more susceptible, such as children and institutionalized
elderly persons. Others at particular risk include the physically and
mentally incapacitated, persons who are bedridden or dependent on
narcotics, and those who have a long history of laxative use.
ETIOP
Several anatomic and physiologic factors contribute to symptoms
of chronic constipation and fecal impaction. e sensory function
of the rectum and anus may be decreased with age or by neurologic
disorders resulting in a higher threshold for sensing rectal distension and urgency. In addition, constipation and slow colonic motility
produce harder, more compact stools, causing less rectal distension
and eventually leading to restriction in their passage through the
relatively xed diameter of the anus. If this cycle perpetuates, formed
stool becomes impacted and overow may occur, leading to passive,
intermittent soiling.
e most common factor predisposing to fecal impaction is constipation, and thus the underlying causes and risk factors are the
same (Boxes 21-1 and 21-2). Numerous medications are associated
with constipation (Box 21-3). In children, the most frequent cause
of fecal impaction is the development of a withholding behavior that
may occur aer a painful or frightening experience with evacuation
at one time, which then perpetuates a cycle of fear of defecation and
further stool retention.
esentation
Pr
ecal impaction can present with dierent signs and symptoms, such as
F
constipation, rectal discomfort, lower abdominal pain, rectal fullness,
tenesmus, or, in some cases, fecal incontinence or seepage. e most
worrisome symptoms are mainly related to secondary complications
that occur especially in patients older than 80 years, in those with heart
and neurologic disease, and in persons for whom treatment is delayed.
e most common complication of fecal impaction is passive fecal
incontinence, also known as overow incontinence, resulting from a
ball-valve eect of the impacted fecal bolus. Loose stool leaks around
the immobile fecal mass, resulting in paradoxical diarrhea, and exacerbating the concomitant incontinence that is oen present. In fact, fecal
impaction is the most common cause of fecal incontinence in nursing
homes. Impaction can also aect the urinary tract, causing urinary frequency, urinary overow incontinence, and even urethral obstruction
or ureteral hydronephrosis when the impaction is a large mass.
102
ATHOLOGY
tin-Perez
BO
X 21-1:
natomic abnormalities
A
M
Anorectal stenosis
Neoplasm
Benign colonic stricture
etabolic
M
Hypokalemia
Hypercalcemia (hyperparathyroidism)
Hypothyroidism
Diabetes
Irritable bowel syndrome
Chronic renal failure
Cystic brosis
eurogenic
N
S
pinal cord injury
Parkinson disease
Multiple sclerosis
etary
Di
ow intake of dietary ber
L
Seeds
unctional
F
O
BO
X 21-2:
dvanced age
A
Alcohol ingestion
Chronic laxative abuse
Decreased colonic motility
Dehydration
Delirium, dementia
Depression
Immobility
Inadequate toilet facilities
Malnutrition
Painful anorectal problems
Postoperative (anorectal surgery, orthopedics)
Sedentary lifestyle
Fecal impaction is responsible for approximately 3% of all
colonic obstructions, especially in patients with spinal cord injuries.
Colonic obstructions present with dilatation of the colon proximal
to the site of impaction, constipation, nausea, vomiting, and abdominal distension. Unresolved fecal impaction can produce a stercoral
Causes of F
egarectum (e.g., Hirschsprung and Chagas disease)
utlet dysfunction
Risk factors f
ecal Impaction
or Fecal Impaction
RECTAL AND PARARECTAL REGION
103
BO
X 21-3:
Constipation
mitriptyline
A
Antacid
Anticholinergic drugs
Antiepileptic agents
Barium
Bismuth
Calcium channel blockers
Clonidine
Iron
Levodopa
Narcotic analgesics
Nitroglycerin
Nicotine
Nonsteroidal antiinammatory drugs
Opiates
Sucralfate
p
erforation of the bowel wall as a result of pressure necrosis from
the fecal mass. e most common sites are the antimesenteric border of the sigmoid and rectosigmoid. e clinical presentation is
usually an acute abdomen associated with fever, vomiting, severe
pain, abdominal tenderness, and an increased leukocyte count. A
stercoral perforation of the bowel wall is an uncommon but lifethreatening complication for older patients and those whose general condition is poor.
DIA
ectal examination is the most important tool for the diagnosis of
A r
fecal impaction. It typically shows hard stool in the rectum, although
the absence of palpable stool does not rule out a fecal impaction
because the stool can be impacted anywhere in the colon or may have
been cleared by prior enemas or suppositories. A plain abdominal
radiograph in the supine and upright positions can identify more
proximal fecal masses and signs of obstruction. ese radiographs
will typically reveal involvement of the rectosigmoid in as many as
70% of cases (Fig. 21-1). Small bowel dilatation occurs in extreme
cases of impaction as a result of an incompetent ileocecal valve. A
radiograph can be the rst diagnostic tool in children, patients with
psychological problems, and in victims of sexual abuse who refuse to
undergo a digital rectal examination.
Computed tomography (CT) is commonly used in the diagnosis
of large bowel obstruction and other complications (Fig. 21-2). Fecaloma is associated with mural enhancement, thickening, and sometimes a lamellar calcication on CT. A stercoral perforation is shown
as a discontinuity of the bowel wall with distention of the colonic
lumen or as fecal material either protruding through the colonic wall
or lying free within the intra-abdominal cavity. Findings of dense
mucosa, perfusion defects, ascites, or abnormal gas associated with
the perforation have the worst prognosis. A diatrizoate meglumine
(Gastrogran) enema can be performed when a small obstructing
colonic lesion is present that is dicult to see on the CT scan. e
dierential diagnosis includes perforation of acute diverticulitis or
colon cancer, and a proctosigmoidoscopy or colonoscopy should be
performed.
TREA
A
ggressiveness of treatment depends on the extent and duration
of the impaction, the general condition of the patient, and the
presence of acute abdominal signs as shown in the algorithm in
Fig. 21-3.
Medications Commonl
GNOSIS
TMENT
y Associated with
FIGURE 21-1 Plain abdominal radiograph showing a large fecal mass
causing dilation of the r
ectal lumen.
Medical Treatment
Digital Evacuation
lthough enemas and suppositories alone may eliminate the
A
impaction, manual fragmentation and extraction of the fecal mass
is indicated first, especially in patients with neurologic conditions. The procedure can usually be performed without induction of general anesthesia, using a local anesthetic gel (lidocaine).
Occasionally spinal or even a general anesthetic may be required.
Valid consent must be obtained. Progressive anal dilatation is performed, first with one finger and then with two fingers lubricated
with a water-based lubricating gel. A scissoring action is used
to fragment the impaction; this action is continued for 20 seconds and repeated every 5 to 10 minutes until stool evacuation
is achieved. In women, transvaginal and perineal pressure may
assist with disimpaction. A rectal tube introduced transanally can
be helpful. The residual stool after manual disimpaction should
be removed with suppositories, rectal lavage, and tap water or
eral oil enemas.
min
or patients with neurologic disorders who experience fre-
F
quent fecal impactions, stimulation of the anus or anal sphincter can help prevent these episodes, even when a lesion is present
above the cauda equina. Special attention should be given to
patients with spinal injuries at T6 or higher who can experience autonomic dysreflexia, which is a sudden and exaggerated
autonomic response to an unpleasant stimulus that presents with
marked hypertension.
Enemas and Colonic Lavage
Large volumes of normal saline solution instilled via an enema may
serve to lubricate and hydrate the fecal mass and facilitate its expulsion in resistant cases. In milder or chronic cases, mineral oil enemas
should be given for 2 to 3 days for maximal eect. Soap, hydrogen
peroxide, and hot-water enemas are not advisable because they may
irritate the mucosa and cause bleeding.
e pulse irrigation enhanced evacuation system (Medica Mark,
Inc., Bualo Grove, Ill.) utilizes the mechanical action of pulsed
water to disrupt dehydrated stool and stimulate colonic peristalsis.
A pulsatile irrigation of water at a temperature between 93°F and
104°F is started; a volume of 40 mL/sec is initially instilled for 2
seconds through a rectal speculum, followed by a passive drainage
time of 4 seconds. e duration of one entire session is generally
1 hour, and it can be repeated if necessary. is procedure is safe
104
ManageMent of fec
al IMpact
Ion
AB
FIGURE 21-2
sagittal planes).
Acute FI
Chronic FI
A computed tomography scan showing impacted feces in the rectal lumen causing proximal dilation of the bowel (transverse and
Stable
Unstable
acute abdomen
Oral solutions/
stool softeners
Severe
Mild to
moderate
Diet
Manual
removal
Manual
removal
Resolution
Colonic irrigation
enemas
Oral solutions
enemas
Yes
Endoscopy
(Gastrografin)
Endoscopy
(Gastrografin)
Surgery
Enemas
FIGURE 21-3
nd inexpensive, and it is useful for both distal and proximal fecal
a
Algorithm for the treatment of fecal impaction (FI).
impactions.
Oral Solutions
If the stool is beyond the reach of enemas and the patient has no signs
of bowel obstruction, oral laxatives can be administered cautiously.
No
Stool Softeners
e dose of mineral oil used is 15–45 mL daily of plain mineral oil
given as a single dose (minimum of 15 mL) or in divided doses. Alternatively, 30 to 75 mL of mineral oil suspension can be administered
daily or 44 to 59 mL of xed-combination mineral oil/magnesium
hydroxide daily given as a single dose or in divided doses. It may be
admini
stered in 100 to 150 mL of fruit juice to improve the taste.
When oil begins to be evacuated, careful manual removal followed by
tap water enemas and an oral cathartic helps eliminate the impaction.
Laxatives
Laxatives based on polyethylene glycol (PEG) are well tolerated, with
minimal adverse eects (in 11% of patients) such as abdominal pain,
atulence, and nausea. PEG is absorbed in small amounts in the gastrointestinal tract, increases the water content of stool, and stimulates
colonic peristalsis. Two PEG formulations are available:
•PEG
nly:
o
ed with juice, coee, or tea to make them more palatable. is
mix
It is r
ecommended
hat
EG-only
t
P
ormulations
f
be
formulation has been demonstrated to be eective and well tolerated when used for fecal impaction and for chronic constipation in
children (0.5 to 1.5 g/kg/day, with a maximum dose of 17 g/day).
• PEG with electrolytes: Itis recommended that formulations
f PEG with electrolytes be mixed with water. e electrolytes
o
ensure that there is virtually no net gain or loss of ions. is
formulation can be administered orally at a dose equivalent
to 17 g in 200 mL water once daily for less than a week and is
proven to be more eective than placebo, lactulose, or lactulose plus enemas for both adults and children.
or patients with associated irritable bowel disease, lubiprostone
F
and linaclotide have been found to be useful, although cost may limit
their use. Lubiprostone is an oral laxative derived from prostaglandins
that activates the chloride channels. It can be administered in adults
with irritable bowel syndrome twice daily (8 µg) and in patients with
chronic idiopathic constipation, 24 µg can be given twice daily. Linaclotide, a peptide agonist of guanylate cyclase that stimulates intestinal
uid secretion and transit, has recently been approved and can be taken
orally once a day.
RECTAL AND PARARECTAL REGION
Chr
onic
E
lective surgery can be performed in patients with chronic, severe
105
constipation and colonic inertia, in patients with repetitive episodes
of fecal impaction, or in cases of giant fecaloma associated with
megabowel. In this setting, colon preparation is advised. A sigmoid
colon resection is indicated when an isolated distended sigmoid
colon is the cause of fecal impaction. Resection with a low colorectal anastomosis or a total proctocolectomy with an ileal J-pouch are
sometimes indicated in patients with megarectum.
PREVENTION
P
revention is the best treatment for fecal impaction because recurrence
is very common. Patients at high risk of constipation and impaction
should undertake aggressive treatment of constipation, as follows:
•Increase
•Institute
stive devices if needed.
si
•Ingestsupplemental
d
aily or a hydrophilic mucilloid).
•Use
a s
day).
•Use
osm
r bisacodyl suppository, or weekly enemas if no bowel move-
o
ment occurs; enemas are generally preferable because they are
more predictable.
•Use
b
f
ecal impaction with soiling.
•Treat
im
paction.
aryber
diet
dicatedtimefor
ade
s
tool
oener
in
diet
(e
takeand
def
aryber
do
.g.,
ter
in
take.
wa
ecationanduseappropiateas
(e
psy
.g.,
s
cusate
odium,
oticlaxativeseverythreeorfourevenings,
iofeedback
un
derlying
herapy
t
di
to t
sorderstoavoid
reat
yssynergic
d
addi
tional
3ginwa
llium,
100 mg t
def
ep
isodesoffecal
ag
ecation
ter
wice
lycerin
and
a
-
Endoscopic Disimpaction
When the fecal mass is beyond the reach of ngers and hence is not
amenable to manual disimpaction and enemas, or when colonic
lavage has failed, endoscopy may be useful. If no signs of bowel perforation or an obstructing lesion are present, colonic irrigation with
a water-soluble contrast medium enema (Gastrogran) directed by
sigmoidoscopy can be eective.
SURGERY
Acute
n stable patients, surgery is the last resort. However, in the setting of
I
an acute abdomen resulting from perforation or peritonitis, surgery is
mandatory. Laparoscopic technique can be applied in the urgent setting
despite the inconvenience imposed by a very dilated, unprepared bowel.
e procedure that is selected in the operating room varies and is dictated
by the conditions encountered. e following procedures may be used:
1. E
xtraction of impacted stool through the anus with dilatation
aer induction of general anesthesia.
xtraction of stool using transanal endoscopic microsurgery.
2. E
3. M
4. C
5. S
ilking forward of the fecaloma to facilitate its expulsion
hrough the anus.
t
olotomy for extraction of a xed, hard fecal mass.
egmental resection of the involved area or a subtotal colecto
m
y with diversion for an acute perforation resulting from stercoral ulceration; this approach has been demonstrated to have
a lower postoperative mortality rate (32%) when compared
with simple closure of the perforation and proximal colostomy
(57%) or exteriorization alone (43%).
CONCLUSION
ecal impaction is a common disorder that is mostly seen in elderly
F
patients and children. A variety of strategies may be required for
management of the condition. Recurrent episodes should be prevented in high-risk patients through aggressive bowel management.
e condition may lead to severe complications, such as obstruction,
perforation, and peritonitis.
g g e
S
u
S t
C
hen CC, Su MY, Tung SY, etal. Evaluation of polyethylene glycol plus
electrolytes in the treatment of sever constipation and faecal impactions in adults. Curr Med Res Opin. 2005;21(10):1595–1602.
Eitan A, Katz IM, Sweed Y, Bickel A. Fecal impaction in children: report
of 53 cases of rectal seed bezoars. J Pediatr Surg. 2007;42(6):1114–1117.
Falidas E, Mathioulakis S, Vlachos K, etal. Stercoral perforation of the sig-
moid colon. A case report and brief review of the literature. G Chir.
2011;32(8-9):368–371.
Halawi HM, Maasri KA, Mourad FH, Barada KA. Faecal impaction: in-hos-
pital complications and their predictors in a retrospective study on 130
patients. Colorectal Dis. 2012;14(2):231–236.
Krassioukov AV, Furlan JC, Fehlings MG. Autonomic dysreexia in acute
spinal cord injury: an under-recognized clinical entity. J Neurotrauma.
2003;20(8):707–716.
Kumar P, Pearce O, Higginson A. Imaging manifestations of faecal impaction
and stercoral perforation. Clin Radiol. 2011;66:83–88.
Kwag SJ, Choi S, Park J, etal. A stercoral perforation of the rectum. Ann Colo-
-
proctol. 2013;29(2):77–79.
Ness W. Digital removal of faeces. Nurs Times. 2013;109(17-18):18–20.
Obokhare I. Fecal impaction: a cause of concern? Clin Colon Rectal Surg.
2012;25(1):53–58.
Prather CM, Ortiz-Camacho CP. Evaluation and treatment of con-
stipation and fecal impaction in adults. Mayo Clin Proc. 1998;73:
881–887.
e d
R
e
a d i n g
106
ManageMent of fec
al IMpact
Ion
Rajagopal A, Martin J. Giant fecaloma with idiopathic sigmoid megacolon: report
of a case and review of the literature. Dis Colon Rectum. 2002;45(6):833–835.
Read NW, Abouzekry L, Read MG. Anorectal function in elderly patients
with fecal impaction. Gastroenterology. 1985;89:959–966.
Savino F, Viola S, Erasmo M, etal. Efficacy and tolerability of peg-only
laxative on faecal impaction and chronic constipation in children.
A controlled double blind randomized study vs a standard peg-electrolyte
laxative. BMC Pediatr. 2012;12:178.
Serpell J, Nicholls R. Stercoral perforation of the colon. Br J Surg.
1990;77(12):1325–1329.
R
P
ODUCTION
INTR
Rectal prolapse occurs when the full thickness of the rectal wall
protrudes through the anal canal. is condition can cause discomfort, bleeding, and incontinence. Rectal prolapse is most commonly seen in older women, but it may occur in both sexes and at
any age. Although the condition has fascinated surgeons for many
years, the optimal surgical approach to rectal prolapse has not been
determined. More than 100 surgical operations have been described,
which can be grouped into perineal and abdominal approaches.
Laparoscopic approaches have become common, with excellent
functional results. Choice of the optimal repair for a patient involves
many factors, including general health and bowel function. Constipation is reported in 30% to 67% of patients with rectal prolapse, and
60% to 80% have a history of incontinence.
PATHOPHYSIOLOGY
e mechanisms by which prolapse occurs remain poorly understood. Brodén and Snellman suggested that prolapse is initiated by a
midrectal intussusception, with its origin 8 to 10 cm inside the rectum. Chronic straining may be a precipitating factor, which might
explain the association of prolapse with colitis cystica profunda and a
solitary rectal ulcer. Another hypothesis relates prolapse and abnormal intestinal motility, such as that seen in slow-transit constipation.
Low anal resting pressures, which are frequently observed in
patients with prolapse, may be caused by continuous rectoanal inhibition or by the dilating eect of the prolapse itself, with or without
pudendal neuropathy. However, other investigators believe that an
initial increase in external sphincter tone may cause a cycle of outlet obstruction, constipation, and straining. An impaired tolerance
to distention, with reduced compliance and tone, may contribute to
incontinence. Other features of patients with rectal prolapse include a
deep pouch of Douglas, redundant sigmoid colon, decient rectosacral
xation, weakness of the pelvic oor, and a patulous anus. Obviously
it is dicult to determine which physiologic alterations are causative
factors and which are a result of the progressive prolapse of the rectum.
Internal rectal intussusception, also called internal or hidden prolapse, occurs when the prolapse does not protrude through the anal
orice. is is oen shown on defecography. Mucosal prolapse is
diagnosed when the mucosa slides on the submucosa and protrudes
into or through the anal canal. It is treated similarly to prolapsing internal hemorrhoids but is thought to predispose to true rectal prolapse.
Andrew J.
ldest straining, or even when the patient stands. Tenesmus, bleed-
mi
ing, and mucus discharge are common, and incontinence may range
from mucus leakage to complete fecal incontinence. Some patients
also report bladder and gynecologic dysfunction and may have prolapse of these organs. ese patients are suitable for multidisciplinary
assessment and management.
Upon physical examination, the anus may be patulous. Visual
observation of everted bowel with concentric folds allows denitive
diagnosis. If prolapse is not obvious, the patient should be examined
while straining on the commode. Examinations with the patient in
the le lateral or prone jackknife position oen fail to reproduce the
prolapse, and prolapse cannot be ruled out in this manner. Occasionally a prolapse is incarcerated, which requires the application of
hypertonic sugar or honey to reduce edema and allow shrinkage and
reduction. A small prolapse can be distinguished from prolapsing
hemorrhoids by observing the concentric folds of the rectal wall, in
contrast to the radial folds of the hemorrhoids. Digital examination
also permits evaluation of sphincter tone and diagnosis of a rectocele.
Anoscopy is a good way to diagnose internal rectal intussusception. As the anoscope is gradually removed, the patient is asked to
bear down and the prolapsing rectal mucosa or rectal wall can be seen
descending toward the anus. Proctosigmoidoscopy facilitates examination of the rectal mucosa and allows one to check for an ulcer, a
lead point, or additional disease. Most patients have already had a
colonoscopy because of their age and the rectal bleeding oen associated with their presentation.
e diagnosis of rectal prolapse is usually straightforward; however, the dierential diagnosis includes hemorrhoids, prolapsing
polyps, and anorectal neoplasia. Conditions such as a solitary rectal
ulcer and colitis cystica profunda are oen associated with rectal prolapse and present with similar symptoms.
Some persons advocate measuring colonic transit time in patients
with constipation. We do not measure colonic transit time routinely,
but only in patients with a history of severe constipation and associated sphincter weakness. Patients with chronic straining should
undergo evaluation for paradoxical contraction of the puborectalis
with anorectal physiologic testing or defecography, so that biofeedback may be instituted prior to repair of the prolapse. e clinical and
nancial value of routine preoperative studies, including anorectal
manometry, pudendal nerve terminal motor latency, colonic transit
studies, and defecography, is unclear. In most patients, an adequate
history and physical examination should provide appropriate information to determine the correct operative approach.
Russ and Conor P. Delaney
CLINIC
ectal prolapse initially occurs only with defecation and straining,
R
and patients are usually aware that it is happening. As the anus dilates
and the rectal attachments loosen, the rectum may prolapse with the
AL FEATURES
PREOPERA
e general health of the patient is an important factor in the choice
of treatment. Abdominal surgery in elderly patients who have signicant comorbidities carries risks that can be avoided with a perineal
approach. However, increasing experience with laparoscopy suggests
TIVE CONSIDERATIONS
107
108
Rect
al P
RolaPse
hat the benets of abdominal prolapse repair may be achieved with
t
greatly reduced morbidity. is suggestion is supported by a recent
National Surgical Quality Improvement Program analysis of 1469
patients older than 80 years undergoing abdominal and perineal
approaches to prolapse repair, which demonstrated that among the
highest risk groups (American Society of Anesthesiologists [ASA] 3
and 4), the relative risk for mortality was four times greater in the
group undergoing a perineal approach.
Incontinence associated with rectal prolapse oen improves aer
surgery and is associated with an increase in both resting and squeeze
pressures. is improvement is likely related to prevention of the
dilating eect of the prolapse and cessation of the constant stimulation of the rectoanal inhibitory reex. Incontinence is reported to
be better aer abdominal repair than aer perineal repair; however,
most large series report improvement in at least 40% of patients
regardless of technique. Sphincter repair is rarely performed at the
time of prolapse surgery, with the option being reserved for those
with complete or near-complete incontinence. In practically all cases,
time is provided for the expected improvement in continence to
occur spontaneously.
Constipation is also a concern because prolapse repair may exacerbate this symptom. Some series suggest that a rectopexy alone can
worsen constipation. is outcome may be related to a redundant
sigmoid loop falling forward over the area of mesh or suture xation
of the rectum to the sacral promontory, causing partial obstruction
at the rectosigmoid junction. Because of this concern, we favor performance of a sigmoid colectomy with a sutured rectopexy in constipated patients. We have observed improvement of preoperative
constipation in 95% of patients who undergo laparoscopic rectal prolapse surgery when a resection rectopexy is reserved for those with
constipation. Conversely, a laparoscopic Well’s procedure for persons
with diarrhea or incontinence can improve continence in upward of
80% of these patients. We avoid lateral ligament division during rectal
mobilization because it also may precipitate constipation.
SURGIC
e goals of surgery are to prevent prolapse while optimizing con-
tinence and bowel function. Prolapse repair may be achieved using
either a perineal or abdominal approach; the primary techniques and
alternatives are discussed in the following sections. Colonic resection
is reserved for persons with signicant constipation because of the
increased risks associated with resection.
erineal Repairs
P
P
erineal repairs can be performed with use of a light anesthetic without paralysis and intubation, and even at times with a local anesthetic
and intravenous sedation. e three main types of procedure used
are anal encirclement (iersch procedure), perineal rectosigmoidectomy (Altemeier procedure), and mucosal stripping/rectal plication (Delorme procedure).
Anal encircling procedures have generally fallen out of practice
because of high failure and complication rates. ey are usually
reserved for persons with the most severe comorbidities who would
not tolerate or should not undergo perineal resection. Such patients
include those with ascites and hepatic failure who are not appropriate
candidates for the transjugular internal portosystemic shunt procedure, followed by abdominal repair. Anal encirclement procedures
are associated with prolapse recurrence rates of 20% to 60% and cause
such complications as breakage and erosion of the wire or suture and
infection.
Altemeier popularized the perineal rectosigmoidectomy in the
1960s. Recurrence rates between 0% and 50% have been reported.
Altemeier initially combined the operation with a levatorplasty,
which may improve continence to a greater degree than just the
AL OPTIONS
resection alone. is approach attempts to remove the prolapsing
segment and use the subsequent brosis to x the rectum in position
in the pelvis. e Altemeier procedure remains the ideal option for
patients presenting with an incarcerated, gangrenous prolapse.
Delorme suggested a less invasive alternative. e rectal mucosa is
stripped from 1 cm above the dentate line, continuing right up to the
top of the prolapsing segment, where it is excised. e bared rectal
muscle is then plicated with concertina-type stitches, and the proximal mucosa is anastomosed to the distal margin of mucosal resection. Submucosal inltration with dilute epinephrine may reduce
perioperative bleeding. Variable recurrence rates have been reported,
but they are generally in the order of 5% to 20%.
Abdominal Pr
Abdominal procedures for rectal prolapse are generally associated
with a recurrence rate in the order of 5%, although recurrence rates
between 0% and 20% have been reported. Abdominal repairs involve
mobilization of the rectum and xation to the sacral promontory with
suture or a prosthetic material or mesh. In an anterior repair, such
as the Ripstein procedure, the mesh is wrapped around the anterior
aspect of the rectum and xed on both sides to the sacral promontory.
Posterior repairs, such as the Wells technique, involve the mesh being
placed behind the rectum and superior rectal artery and xed to the
sacrum before being wrapped around both sides and xed to the lateral
mesorectum. Although recurrence rates are generally less than 10%,
anterior wraps may be complicated by stenosis and obstruction. Posterior xation avoids stenosis and may reduce constipation. Although
a variety of materials have been used to x the rectum, we favor use of
polypropylene mesh to reduce the risk of septic complications, which
are reported in 3% to 4% of cases using the Ivalon sponge.
e rectum is usually mobilized by dissecting posteriorly in the
presacral space down to the pelvic oor, although the extent of lateral
dissection varies. Division of the lateral ligaments has been evaluated
in two small prospective randomized trials. One study suggested no
dierence in postoperative functional outcome, but the other study
showed signicantly less constipation with lateral ligament preservation, at the cost of increased recurrence rates.
Abdominal repairs may be performed with or without a concomitant bowel resection. us, resection rectopexy incorporates resection of the sigmoid and upper rectum. Fixation of the rectum is likely
achieved by the perianastomotic brosis, with sutures providing
additional xation of the lateral tails of the mesorectum to the sacral
promontory. Recurrence rates are generally in the order of 2% to 8%,
but potential morbidity of a colorectal anastomosis exists. Some authors
have advocated a formal anterior resection, but this procedure provides
an increased potential for morbidity without reducing recurrence rates.
We perform anterior dissection only when necessary in patients with
a very distal prolapse, which requires circumferential mobilization to
fully reduce the intussusception. is reduction is conrmed by digital
examination at the completion of rectal mobilization.
Laparoscopic colorectal procedures are increasingly being used to
accelerate recovery aer major abdominal surgery. Smaller incisions
result in fewer wound hernias and admissions for bowel obstruction.
Most studies also demonstrate fewer complications and a lower direct
cost of care by virtue of reduced postoperative pain, earlier introduc
t
ion and tolerance of diet, and shortened length of hospital stay. e
surgeon can perform exactly the same operation laparoscopically as
when using the open approach; the primary dierence is that the
largest wound is the 10-mm incision for the camera port. When a
laparoscopic resection rectopexy is performed, a 3- to 4-cm le lower
quadrant muscle-splitting incision is also used. e rectum is xed to
the sacral promontory using a suture or stapled technique. Mesh can be
used as in open surgery. Many series describe no cases of recurrence.
Excellent outcomes can be achieved with laparoscopic resection rectopexy with resultant improvements in constipation, incontinence,
and outlet obstruction rates when compared to open surgery. Several
ocedures
-
RECTAL AND PARARECTAL REGION
109
in
vestigators have found that use of the laparoscopic Wells procedure
is associated with reduced constipation and no recurrences, with a
reduction in length of stay and in costs compared with open repair.
Performance of a laparoscopic suture rectopexy without mesh or
resection has been associated with a 7% recurrence rate.
e surgical approach used is the same as that used for open surgery. e presacral space is entered and a posterior rectal mobilization is performed to the level of the pelvic oor. We do not divide
the lateral ligaments. For a Wells rectopexy, a precut piece of mesh is
passed down a port and tacked or sutured to the sacral promontory
in the midline. e edges are then sutured to the lateral mesorectal
tissue to maintain rectal support. In patients undergoing a resection,
the upper rectum is transected with an endoscopic stapler and passed
out through a small le lower quadrant muscle-splitting incision.
e proctosigmoidectomy is completed and the anvil of a circular
stapler is inserted in the proximal bowel before it is returned to the
abdomen. e anastomosis to the rectal stump is completed before
suturing the lateral mesorectal tissue to the sacral promontory for
additional support. We performed a case control study of 111 patients
to compare laparoscopic and open surgery for rectal prolapse, with
5-year follow-up. Compared with the open surgery cohort, the laparoscopic cohort had a shorter hospital stay (3.9 vs. 6.0 days) and
improved constipation scores.
Laparoscopic ventral rectopexy has been advocated for patients
with signicant constipation in an eort to avoid resection. is
approach avoids posterior dissection and its potential for nerve damage by using anterior dissection and mobilization of the anterior wall
of the rectum with placement of mesh anteriorly and xated to the
sacrum. Avoidance of posterior dissection has been suggested to
improve obstructive defecation. In a case series described by D’Hoore
and colleagues, resolution of obstructed defecation was found in 16
of 19 patients with this technique. Additionally, a recent systematic
review found that patients undergoing ventral rectopexy without
posterior dissection were signicantly less constipated postoperatively compared with preoperative rates.
Robotic-assisted laparoscopic surgery for rectal prolapse has also
been described, providing the benets of minimally invasive surgery, but with extended operative times and prohibitive costs. us,
although robotic surgery may play a role in the management of rectal
prolapse in the future, its benets currently do not warrant exploration in our practice.
Recommendations
M
any options exist for repair of rectal prolapse. In a major review,
Kim et al studied 188 perineal rectosigmoidectomies and 160
abdominal resection rectopexies performed over a 19-year period.
Although the morbidity was lower for perineal repairs, recurrence
rates were increased from 5% to 16%. In our opinion, laparoscopy
helps reduce postoperative morbidity, allowing for a safe abdominal repair in a larger number of patients. Consequently, the reduced
recurrence rates of abdominal surgery can be oered to older patients
who previously would have been oered a perineal repair.
us, we use a laparoscopic Wells rectopexy to treat patients who
do not have constipation or who have diarrhea or incontinence, and
we use a laparoscopic resection rectopexy to treat patients with constipation. Perineal approaches are reserved for patients who are very
unt medically; we use both the Delorme and Altemeier approaches,
and prefer using the Delorme approach in patients with poor
continence.
oblems
Pr
P
ersistence of residual rectal mucosal prolapse (which occurs in 5%
to 10% of cases) is not considered to be a true recurrence and can be
treated with elastic banding.
P
atients whose diculties with continence persist should be
observed for improvement for up to 6 or 12 months, unless symptoms
are extremely severe and warrant earlier sphincter repair or additional operative intervention for fecal incontinence.
A solitary rectal ulcer, which is present in approximately 12%
of patients with a prolapse, is oen considered to be a complicating issue. A solitary ulcer should be treated separately. If the ulcer
is associated with prolapse, then repair of the prolapse should be
sought. If the ulcer is not associated with prolapse, then initial
treatment involves correction of straining and improved defecation
practices.
Internal intussusception, which is diagnosed by barium studies or
defecating proctography, is not automatically an indication for surgical repair. Many asymptomatic patients are shown to have an internal
intussusception upon defecating proctography, and a surgical repair
is generally not warranted. Patients should be fully evaluated for other
possible causes of their symptoms. Surgical repair is generally
reserved for those with concomitant obstructive defecation or additional pathology, such as solitary rectal ulcer, only aer exhaustion of
conservative measures (pelvic oor physical therapy).
When rectal prolapse occurs in conjunction with urogenital prolapse or other pelvic oor disorders, a combined approach by colorectal, gynecologic, and urologic surgeons may be indicated. For this
patient cohort, Sullivan etal have reported total pelvic mesh repair
in 236 patients, involving the placement of mesh from the sacrum to
the perineal body and around the vagina. In this report there were
no recurrences, and patients had a 70% satisfaction rate, but 10%
required a repeat operation because of problems with the mesh. A
perineal approach to the rectal prolapse also can be used, combined
with a perineal colporrhaphy.
MANA
GEMENT OF RECURRENT
PROLAPSE
R
ecurrence generally occurs a mean of 18 to 24 months postoperatively.
Repeat repair usually provides an excellent outcome for treatment of the
prolapse; however, there is little improvement in other functional problems such as constipation and incontinence. Prior to a repeat repair, an
extensive investigation of these patients should be performed to elucidate
factors that might predispose to recurrence, such as slow-transit constipation and paradoxical contraction of the pelvic oor.
If a resection is performed, any prior anastomoses must be
resected to avoid leaving an ischemic segment. Some investigators
would suggest a perineal repair aer a failed abdominal repair, and
vice versa. In fact, both types of repair are feasible, with inadequate
evidence in the literature to determine an ideal strategy. Our preference is to perform repeat abdominal repair except in the most unt
patient, reserving laparoscopy for patients for whom a perineal
approach has failed. We have performed repeat abdominal repair
in a number of patients with prolapse who have been referred to
us aer undergoing prior open or laparoscopic approaches at other
institutions.
u
S
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