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Perineal Repair of Rectal Prolapse
Richard Nelson
What Are the Options?
A number that has floated around medical literature for several generations is 130.
One hundred thirty operations have been described for the treatment of rectal
prolapse. That has been interpreted to mean that none of them work very well. Or
that it is still uncertain what the pathophysiology is of rectal prolapse: a hernia? an
intussusception? a motility disorder? inevitable result of a defecation disorder? not
enough lumbar lordosis? and so on.
Are there really 130? I do not know anybody who in fact has made the count.
The most available methods for the most part are fairly simple in their conception,
which is to ignore the pathophysiology and either suspend the rectum from above to
prevent it dropping, or reduce the prolapse from below to prevent it from finding its
way out. And in some cases remove a length of colon in the belief that what
attaches the colon uphill will prevent further dropping. In this chapter, the focus
will be on procedures accomplished from the perineum to prevent future prolapse.
Without much data (i.e., randomized controlled trials—RCTs) to support this, there
is also the hope that these might in some way ameliorate the defecation disorder that
is always part of prolapse.
8
R. Nelson (&)
Epidemiology/Biometry Division, School of Public Health,
University of Illinois at Chicago, 1603 West Taylor, Room 956,
Chicago, IL 60612, USA
e-mail: altohorn@uic.edu
© Springer International Publishing AG 2017
H. Abcarian et al. (eds.), Complications of Anorectal Surgery,
DOI 10.1007/978-3-319-48406-8_8
147
148 R. Nelson
The procedures discussed will be:
Perineal Proctectomy, aka the Altemeier procedure
Anorectal mucosectomy, aka Delorme procedure
Anal circlage, the Theirsch, using wire, silastic, fabric, or biologic materials
Fully stapled perineal proctectomies (TRANSTAR and PSP)
All of these are often combined with a striated muscular tightening of the pelvic
outlet/anal canal. Or anal circlage with a foreign body. My experience with the
former I will deal with quickly and not again. A “levatorplasty” or otherwise
plication of uninjured external sphincter feels like an anal canal with restored
muscle tone immediately afterwards, and that tightness is totally absent 4 months
later. One has to wonder about how possible it is to tighten striated muscle that has
not been previously injured, as in childbirth, in which case the muscle is reinforced
with scar tissue.
The chapter will not compare efficacy. That is way too difficult to sort out and is
better described, as far as it can be, in the Cochrane review [1].
It is important first to deal with the elephant in the room. Are there any reports I
found of a previously continent patient made incontinent by any of these procedures? Not that I could find.
Incontinence persisted in a very variable percentage of patients post surgery, as
one would expect when the pelvic nerves and muscles were inured for very variable
lengths of time by an obturation which is not much different that a vaginal delivery
from the perspective of these pelvic nerves and muscles. But the case series
available show pretty routinely some degree of improvement after prolapse repair.
So, on to complications. First the disclaimers. This is not a systematic review.
The casual reports (i.e., case series, case reports, etc.) are so numerous and so
haphazard in their trip to publication that an accurate assessment of the statistical
risk of each complication would be at best very inaccurate and, even more, tedious.
The most serious ones will be discussed, as in “How could this have happened?
And is it likely to happen again?” Beneath that here is a scoring system for complications that is pretty broadly used: numbered from 1 to 4: 1 being minor complication requiring no interventions, four being death, three being loss of an organ,
or lasting disability and two has lots of subdivisions depending on the invasiveness
of the correcting intervention [2] (Fig. 8.1).
Altemeier Procedure
Trans-Anal Evisceration After Perineal Proctectomy
First of all, there is an urban myth that this could happen without previous surgery if
one is corpulent and flushes an airplane toilet without first standing up, because of
8 Perineal Repair of Rectal Prolapse 149
Fig. 8.1 A rectal prolapse
the negative pressure flushing mechanism. This has never been reported. There is
one case report in JAMA in 1987 without photographs or an eye witness in which
the individual involved said. “It all came out” [3]. Whether this was a small bowel
evisceration through a ruptured rectum, or simply a rectal prolapse is not clear in
that article. And in any case it was not in an airplane, but a cruise ship. There are
documented cases with photographs and detailed clinical histories of children sitting on swimming pool drains with massive trans-anal small bowel eviscerations
and massive small bowel loss [4]. There are also case reports of rectal rupture with
small bowel evisceration in patients with known rectal prolapse, and no particular
triggering event [5, 6 ] (Fig. 8.2). This seems also not to be rare. Morris cites 53 case
reports in 2003 going back to the original report by Brodie in the Lancet in 1827
[7]. Screening PubMed since 2003, 15 more cases would be added for a total of 68
case reports. Not all of these were in patients with rectal prolapse, but at least 70%
were.
To these I add one published case report of the same event shortly after a
perineal proctectomy with presumed rupture of the anastomosis ([8], Fig. 8.3), and
add an additional case of my own, never published. She was a patient from a mental
hospital and prone to rather wild behavior. The photograph of my patient was taken
the evening of her surgery, (Fig. 8.4), and immediately repaired by reduction of the
small bowel via laparotomy and reinforcement of the anastomotic line, through
which the small bowel had come. She had thereafter an uneventful recovery. In the
published case report the prolapse did not occur until four days after surgery while
straining to defecate in a 42-year-old male. The small bowel was necrotic by the
time he made it back to the hospital and to surgery, so the anastomosis was taken
down, the ileum resected and an end colostomy formed. A grade 4 surgical complication [2].
So did these two cases occur due to can anastomotic leak, a poorly constructed
anastomosis, or a sudden vast increase in intra-abdominal pressure stressing an
150 R. Nelson
Fig. 8.2 Eviscerated small intestine in a patient with known rectal prolapse
Fig. 8.3 Eviscerated small
intestine in a patient who had
had an Altemeier 4 days
earlier
anastomosis? The other eviscerations that have been reported have resulted in the
absence of an anastomosis. In the case of swimming pools and toilets, there was a
large pressure gradient across the rectal wall. In the case of preexisting rectal
prolapse, might there have been a solitary rectal ulcer not previously diagnosed? In
any case it is not a rare event.
Anastomotic leaks have been often reported after perineal proctectomy,
including four in the original paper by Altemeier in 1971 [9]. (Digression. Perineal
proctectomies had bee n done for many years before Altemeier’s 1971 series was
published [10]. To the original operation he added a levatorplasty. But with the
passage of time virtually all (non-stapled) perineal proctectomies have become
8 Perineal Repair of Rectal Prolapse 151
Fig. 8.4 Eviscerated small intestine in a patient who had had an Altemeier 8 hours earlier
known as Altemeiers.) There were eight leaks in a rather massive series of 518
patients reported from the University of Minnesota [11], a leak rate that compares
very favorably with the published risk of leak of colonic anastomoses of between 7
and 8% in Holland [12]. Though some are described as asymptomatic, it is hard to
imagine how or why they could have been found in the absence of symptoms.
Many were treated by prolonged courses of intravenous antibiotics and bowel rest.
A grade 2 complication. If a pelvic abscess results from the leak, trans-anastomosis
drainage has been effective. In some cases stomas were done as well, which implies
that the patient must have been pretty sick. No additional details were given. One
case of massive surgical emphysema was reported extending through the
retroperitoneum all the way to the patients face early in the post operative period
[13] (Fig. 8.5a and b).
Ischaemia
Rectal ischemia or infarctions are not an unusual presentation of rectal prolapse that
becomes incarcerated [14]. Indeed, perineal proctectomy is well suited to that
presentation and as long as both ends after resection are healthy. However, acute
ischaemic infarction of the segment of colon above the anastomosis in an Altemeier
is also worth mentioning. There are no published case reports of such an event, but
there is a case with which I am familiar. A patient had had a perineal proctectomy.
152 R. Nelson
Fig. 8.5 a Emphysema seen at surgery in a patient with development of subcutaneous
emphysema early in the postoperative period. b Mapping on CT of the extent of the patient’s
emphysema
8 Perineal Repair of Rectal Prolapse 153
She had a lower midline scar on her abdomen that was many years old and she was
unable to tell where it came from. It was found too late to be from a previous
sigmoid resection for an unknown disease. There was a segment of sigmoid colon
that lost its blood supply from both above and below, and nothing available in
between. The result of that event, because it was not suspected was not good.
However before abandoning perineal proctectomy because of the risk of
ischemia, be aware that there is also a case of rectosigmoid ischaemia after a
Delorme procedure, which is only a very limited mucosectomy [15]. How could
such a thing happen? The published case report offers no suggestions beyond a
proximal impaction (Fig. 8.6).
Bleeding
Bleeding is a prominent risk in all of perineal surgery from hemorrhoids to fistulas,
and certainly for all perineal procedures for prolapse, with the possible exception of
injection sclerotherpy [16, 17] (Injection sclerotherapy is also a procedure for rectal
prolapse, especially in children, but with no reported complications). There are
individual case reports of the need to return to surgery to suture the bleeding
anastomosis but that is not unique to the Altemeier. But there is a special risk
related to perineal proctectomy. Once the rectal mucosa and muscularis are divided
proximal to the dentate line, mesenteric vessels are serially divided and ligated. As
that progresses upwards, every surgeon who does this procedure thinks more and
more about how well controlled the mesenteric division is. If a vessel slips away it
will retract into the upper pelvis, completely out of reach. Laparotomy is the only
option regardless of the fragility of the patient. There are no case reports of this
occurring. None of the larger series specifically mention it. It has not happened to
me. But I have spent plenty of time worrying about it.
Stricture, etc
Anastomotic stricture has been reported but is rare, in the one to 2% range. Of
course it is easily accessed for repair. Urinary difficulties are frequently mentioned
in reports, common in all disabled or hospitalized patients [18, 19].
Delorme Procedure
This operation interestingly, in cruising PubMed, is discussed in by far the most
publications of all perineal operations for rectal prolapse. Yet it is one with which I
have relatively little exposure. It is quite simple: a sleeve mucosectomy and corrugation of the submucosal muscle with anastomosis of the mucosa over the corrugated muscle. So it is sort of an autologous Thiersch. This and all treatments of