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430
J.G. Williams
However, there are two major drawbacks to anterior resection as a treatment for
rectal prolapse. Removal of the rectum and replacement by more proximal colon
will result in functional disturbance as the reservoir function of the rectum will be
lost. Furthermore, anterior resection is associated with a recognized risk of anasto-
motic leakage, greater than that associated with sigmoid colectomy. For these rea-
sons, most surgeons have avoided this approach, and it is regarded to be of historical
interest only.
Perineal Rectosigmoidectomy
Perineal rectosigmoidectomy is an operation that predates the description of the
procedure by the author whose name is traditionally associated with this operation,
William Altemeier of Cincinnati. Early descriptions of the operation amounted to
little more than amputation of the prolapsed rectum via a perineal approach, with
coloanal anastomosis. High recurrence rates led to disillusionment with this surgi-
cal approach. Altemeier, in the 1950s, popularized this operation by reporting good
results and stressing the importance of mobilization of all the redundant rectum and
colon, including most of the sigmoid if necessary [
24 ] . Although the operation suf-
fers from one of the main drawbacks of anterior resection – substitution of rectal
reservoir by narrow proximal colon, the procedure is associated with low morbidity
and can be performed on elderly frail patients, who would otherwise be unsuitable
for an open transabdominal approach. It could be argued that the place of such
perineal repairs will be usurped by laparoscopic proctopexy. However, a laparo-
scopic approach is not appropriate in very frail patients, whereas perineal repairs
can be performed under regional anesthesia, if required.
The principle of this operation can be diffi cult to appreciate if it has not been
observed. Like all perineal operations, the procedure is easiest to perform with the
patient in the prone jackknife position, which affords better exposure and illumina-
tion within the pelvis and access for assistants to the operative fi eld. However, the
operation can be performed in the lithotomy position, which many anesthetists fi nd
preferable when dealing with frail patients. The operation is usually performed
under light general anesthetic, but can be performed under regional anesthesia and
mild sedation.
The anal canal is effaced with retractors. Gelpi retractors can be used, but a
superior view is obtained with the Lone Star™ retractor, which consists of a
self-retaining ring, held in place with eight elasticated hooks. The rectum is then
gradually prolapsed from the pelvis with Babcock clamps until the prolapse is
fully evident. An incision is made in the effaced lower rectal wall, roughly 1 cm
above the dentate line. The incision is carried through the rectal mucosa, submu-
cosa and muscle wall into the perirectal fat.
The next phase of the operation is to divide the mesorectal structures until the wall
of the inner part of the emerging rectum is reached. Anteriorly, the pouch of Douglas
is usually opened early in the dissection, and this helps with orientation and the
dissection. Once the wall of the inner part of the rectum is reached, dissection is
431
29 Rectal Prolapse
performed close to the muscle tube, sequentially dividing and ligating mesorectal and
then mesocolic structures, thus gradually mobilizing the rectum and sigmoid from the
pelvis through the anus. The peritoneum is breached during this dissection, usually
fairly early on, and this allows regular digital assessment of the degree of redundancy
in the proximal colon as the dissection proceeds. Eventually, the dissection will start
to become more diffi cult, and it will be appreciated that the proximal sigmoid colon
lies fairly straight within the pelvis. In this way, a segment of 15–25 cm of rectum,
and sigmoid colon can be excised (sometimes, much greater lengths are mobilized).
At this stage, a levatorplasty can be performed either anteriorly, posteriorly, or
both anteriorly and posteriorly. The evidence in favor of levatorplasty as a means of
improving continence is fairly circumstantial, but levatorplasty does narrow the pel-
vic fl oor and buttress the repair, possibly helping to prevent recurrence [ 25 ] . The
fi nal phase of the operation is to excise the mobilized colon and rectum and perform
an anastomosis between the proximal colon and the upper anal canal. The inner tube
of bowel is transected fl ush with the anus. There is usually a signifi cant size discrep-
ancy between the narrow proximal colon and the dilated anal canal. Four scout
sutures are placed, one in each quadrant between the inner tube and the outer rectal
stump. A single layer of all coats interrupted long-term absorbable sutures are placed
between these scout sutures. The anastomosis returns to the pelvis when complete,
and the retractor is removed. It is also possible to perform the anastomosis with a
circular stapling device, although this does not seem to have any particular advan-
tage over what is usually a fairly easy coloanal anastomosis. The procedure is asso-
ciated with little pain, and the patient is usually ready to leave hospital in 3–5 days.
The reported recurrence rates after perineal rectosigmoidectomy vary between 0
and 50% (Table 29.2 ). The functional results of rectosigmoidectomy have varied
from series to series. Both Altemeier and Porter noted a high incidence of inconti-
nence following this operation [ 24, 26 ] . Marked improvement in postoperative con-
tinence has been demonstrated when posterior levatorplasty is combined with
rectosigmoidectomy. Prasad et al. noted that 22 of 25 incontinent patients became
fully continent within 4 weeks of surgery [ 27 ] . A similar high rate of improvement
was reported by Ramanujam et al. [ 28 ] .
Table 29.2 Results of perineal rectosigmoidectomy for rectal prolapse
Author Date No. Follow-up Recurrence Morbidity
Porter [
26 ] 1962 110 1–14 years 55 (50%)
1
Gabriel [
29 ] 1963 131 N/A 16 (12%) 2
Altemeir et al. [
24 ] 1971 106 N/A 3 (3%) 0
Prasad et al. [
27 ] 1986 25 <3 years 0 0
Finlay and Atchison [
30 ] 1991 17 9–40 months 1 (6%) 1
Williams et al. [
31 ] 1992 114 3–90 months 11 (10) 0
Ramanujam et al. [
28 ] 1994 72 N/A 4 (6%) 0
Kim et al. [
32 ] 1999 183 47 months 29 (16%) 0
Chun et al. [
25 ] 2004 109 28 months 18 (16%) 1
Altomare et al. [
33 ] 2009 93 41 months 17 (18%) 0
N/A not available
432
J.G. Williams
29.5.2.3 Rectal Plication
Rectal mucosal sleeve resection with muscle plication for the treatment of rectal
prolapse was fi rst described by Edmond Delorme, a prominent French military sur-
geon, in 1900. He treated three male patients, one of whom died as a result of septic
complications. Although sporadic reports of the use of this operation have appeared
since then, there has been a resurgence of interest in this technique in the more
recent surgical literature.
The principle of the operation is to reduce the prolapse and return it to the pelvis,
without resection of rectal muscle, thus preserving some of the storage function of
the rectum. This is achieved by stripping the mucosa from the prolapsed segment of
rectum and plicating the denuded rectal wall to form a suprasphincteric muscular
pessary, which prevents further prolapse. The operation can be performed in either
the lithotomy position or the prone jackknife position. Regional or general anesthe-
sia is appropriate. The prolapse is reproduced, and the submucosal plane is infi l-
trated with Xylocaine containing 1:100,000 Adrenalin, to facilitate the dissection
and limit any bleeding. A circumferential incision is made through the mucosa,
1 cm proximal to the dentate line. The submucosal plane is then developed circum-
ferentially, using scissor dissection, electrocautery, or superfi cial strokes with a
small scalpel blade. The dissection proceeds until the apex of the prolapse is reached
and resistance to downward traction on the mucosal sleeve is felt. The mucosal
sleeve is amputated, and the mucosal edges are reapproximated with circumferen-
tial, longitudinal sutures that also plicate the denuded rectal wall. Traditionally,
eight sutures are placed, taking several bites of the denuded rectal wall. When all
sutures are inserted they are tied, plicating the rectal wall and bringing the cut edges
of the mucosa together. Gaps in the suture line can be fi lled in with additional
sutures. The plicated rectal wall returns to the pelvis as the sutures are tied.
Different authors have emphasized important modifi cations to the basic technique.
By making the initial incision proximal to the dentate line, the anal transition zone is
preserved, which may be an important part of the continence mechanism [
34 ] . Some
authors stress that the mucosal dissection should extend upwards inside the prolapse
to produce a mucosal tube twice the length of the prolapse. The mucosa is transected
at the point where the rectum narrows down [ 35– 37 ] . Care should be taken to transect
the mucosa fl ush with the limit of mobilization to preserve its blood supply and to
use full-thickness sutures at the mucosal anastomosis to reduce the risk of anasto-
motic separation. Most authors agree that careful insertion of the plication sutures is
important to obliterate any potential dead space beneath the mucosa by taking mul-
tiple bites of the rectal wall.
The recurrence rate after the Delorme procedure varies from 0% to 30%
(Table 29.3 ). It is likely that much of this wide discrepancy in recurrence rates
refl ects differing lengths of follow-up; very few series use Kaplan Meier statistics to
calculate recurrence rates. The operation also appears to have a benefi cial effect on
continence, but this is not as predictable as that seen following rectopexy.
Constipation and pelvic pressure symptoms appear to be relieved in most patients,
whereas the functional results are less predictable in patients with loose stools, who
are likely to remain incontinent.
433
29 Rectal Prolapse
The operation is well tolerated by elderly, frail patients and is a popular choice
for this group of patients, particularly if the prolapse is not large. Complications
following Delorme’s operation are infrequent and usually minor. Primary hemor-
rhage can occur, but seldom requires operative intervention. Nonhealing of part of
the circumferential suture line can occur and manifest as discharge or bleeding, with
the defect in the suture line readily palpable on rectal examination. This will usually
resolve with healing by second intention. Many surgeons will administer a course of
suitable antibiotics such as co-amoxiclav. Complete separation and unraveling of
the muscular plication is unusual, but problematic when it occurs. As there is com-
plete separation of the two cut edges of mucosa, healing will result in a stricture in
the lower rectum. Patients may experience signifi cant pain and mucus discharge
during this healing process and may have a better quality of life with a stoma.
29.6 How Do You Select the Best Operation
for Rectal Prolapse?
From the foregoing section, it can be seen that there is no one ideal operation for the
treatment of rectal prolapse, therefore clinical judgment is required when advising
patients of the options. Two factors have to be considered; the magnitude and likely
morbidity of the procedure and the patient’s relative fi tness to withstand surgical
intervention. Traditionally, transabdominal repair was advised for younger and fi tter
patients as it offered a better chance of controlling the prolapse on a long-term basis
with less impact on anorectal function. Perineal repairs were reserved for older and
frailer patients, where poorer functional results and higher recurrence rates were
traded off for lower potential morbidity.
The choice between perineal rectosigmoidectomy and Delorme’s operation usu-
ally depends on surgeon’s preference. However, perineal rectosigmoidectomy can
be diffi cult to perform on a patient with a small prolapse or a high take-off of the
prolapse, and Delorme’s operation can be challenging in a patient with a large rectal
Table 29.3 Results of the Delorme operation for rectal prolapse
Author Date No. Follow-up Recurrence Morbidity
Christiansen et al. [
38 ] 1981 12 3 years mean 2 (17%)
None reported
Gundersen et al. [
35 ] 1985 18 42 months mean 1 (6%) Dehiscence 2
Watts et al. [
42 ] 1985 101 36 months mean 30 (27%) Dehiscence 1
Monson et al. [
37 ] 1986 27 11–65 months 2 (7%) None reported
Houry et al. [
36 ] 1987 18 18 months mean 3 (17%) Rectal stenosis 1
Abulafi et al. [
39 ] 1990 22 3–70 months 1 (5%) Rectal stenosis 2
Oliver et al. [
40 ] 1993 40 1–11 years 9 (22%) Rectal stenosis 5
Lechaux et al. [
41 ] 1995 88 33 months mean 11 (14%) Bleeding 4
Watkins et al. [
43 ] 2003 52 63 months mean 5 (10%) Bleeding 4,
dehiscence 1
Lieberth et al. [
44 ] 2009 76 42 months mean 11 (14%) Dehiscence 4
N/A not available
434
J.G. Williams
prolapse, and sometimes the choice of perineal technique can only be made with the
patient under general anesthetic when the true extent and nature of the prolapse is
appreciated.
The advent of laparoscopic approaches has somewhat blurred this distinction,
with transabdominal laparoscopic repair being offered to patients where an open
procedure may be inappropriate. What trial data is available is fl awed because of low
numbers. Consequently, a surgeon treating patients with rectal prolapse needs to be
able to evaluate a patient as to the extent of the prolapse, associated functional prob-
lems, and their general physical condition. The surgeon also needs to be competent
at performing several surgical procedures to correct the prolapse and involve the
patient, family, and carers in any discussion as to the most appropriate approach.
29.7 Special Situations
29.7.1 Recurrent Prolapse
Recurrence of rectal prolapse is more common than most surgeons would like to
admit. Recurrence after transabdominal repair is less frequent than after perineal
repairs. Early recurrence usually refl ects a failure of surgical technique or poor
selection of operation for the particular situation. Late recurrence occurs as a conse-
quence of persistence of the forces that caused the prolapse in the fi rst place.
Diagnosis of recurrent prolapse is unusually more straightforward than the initial
diagnosis as the patient is aware of the likely cause of their symptoms. However,
care should be taken to differentiate between mucosal prolapse and full-thickness
prolapse, particularly as rectal mucosal prolapse is quite common after prolapse
repair. Symptomatic mucosal prolapse is dealt with by rubber band ligation when it
is localized to one part of the anal margin or sleeve resection when it is more exten-
sive. Stapled resection (procedure for prolapse and hemorrhoids, PPH) could also
be considered, especially following rectopexy where there is not a preexisting
coloanal anastomosis.
Treatment of recurrent full-thickness rectal prolapse is more of a problem.
Similar issues need to be considered as when selecting the best procedure for pri-
mary prolapse, namely, the fi tness and mobility of the patient and the extent of the
prolapse. However, a further important consideration will be the nature of the previ-
ous repair performed. While most surgeons would agree that, in general, it is best
not to repeat an operation that has already failed, in rectal prolapse, repeating cer-
tain procedures may be the best option for the patient. It is feasible to repeat both
Delorme’s operation and perineal rectosigmoidectomy, but in both instances, initiat-
ing dissection in the correct plane can be challenging, although the later stages of
dissection are usually more straightforward as fresh tissue planes are entered.
Transabdominal repair of recurrence after Delorme’s operation is usually relatively
435
29 Rectal Prolapse
easy to perform, provided the patient is fi t enough to undergo the procedure.
Dissection should be performed to the pelvic fl oor to ensure that the lower rectum
is adequately mobilized before it is fi xed to the sacrum. Laparoscopic rectopexy
may offer some benefi ts in a frail patient.
Transabdominal repair following perineal rectosigmoidectomy is a more diffi -
cult procedure. During perineal rectosigmoidectomy, the rectum is dissected off the
mesorectum, remnants of which remain in the pelvis. During subsequent transab-
dominal repair, once the pelvic colon is mobilized, it can be diffi cult to identify
suitable mesorectum with which to perform sutured rectopexy, and suspension of
the rectum from the sacrum by direct attachment of mesh to the rectum may be
required. Surgery in the pelvis for recurrent prolapse can be challenging as tissue
planes have been violated. This needs to be borne in mind when contemplating a
laparoscopic approach.
Constipation is likely to have played a role in the etiology of recurrent prolapse,
especially late recurrence. For this reason, bowel function should be assessed in
detail and consideration given to performing concomitant colonic resection, if not
already part of the initial procedure. Occasionally, functional problems are so pro-
found that the only effective surgical option is rectal resection and an end
colostomy.
29.7.2 Rectal Prolapse in Male Patients
The etiology of rectal prolapse in males is likely to differ somewhat from those in
females. In part, this is because the prostate forms a fi xed point in the pelvis, pro-
viding support to the rectum far beyond that present in the female pelvis.
Furthermore, there is less room in the male pelvis to allow movement of the rectum.
For these reasons, rectal prolapse is much less common in males, accounting for
5–10% of patients in most published series. Rectal prolapse tends to occur at a
younger age in males and, in nondeveloped countries, is associated with chronic
enteric infections such as schistosomiasis, which leads to chronic straining. In
developed countries, psychological problems often play a part in the etiology of
rectal prolapse.
The challenge of treating rectal prolapse in males is twofold: correcting the pro-
lapse, but at the same time avoiding damage to the pelvic nerve supply and conse-
quent sexual and bladder dysfunction. Traditionally, perineal approaches were
favored in the belief that there was less risk of inadvertent nerve damage. However,
it has been shown that nerve damage can occur with transanal dissection during
perineal rectosigmoidectomy, although it is avoided with Delorme’s operation.
Furthermore, many patients are relatively young, and transperineal repairs will not
offer the best chance of long-term control of the prolapse. For this reason, transab-
dominal repair is appropriate, but careful discussion with the patient of the risks and
benefi ts of the procedure is required.
436
J.G. Williams
29.7.3 Incarcerated Rectal Prolapse
True incarceration of full-thickness rectal prolapse is an unusual complication.
More common is a rectal prolapse that is permanently out, but is easily reduced with
the patient lying comfortably. An incarcerated prolapse is likely to be tender (but
appreciation of this depends on the patient’s mental state). It usually has a dusky
color, but only in extreme cases of neglect is the prolapse likely to have infarcted. If
the prolapse is obviously necrotic, then surgery is the only course of action, and
perineal resection is an appropriate technique as the level of infarction does not
involve the anal canal, and there will be suffi cient viable anal canal and lower rectal
wall to perform an anastomosis.
If the incarcerated prolapse is deemed to be viable, attempts at reduction are
worthwhile. A useful trick is to coat the prolapse with granulated sugar and wait
15–30 min for the osmotic effect of the sugar to draw out edema from the prolapse
and facilitate reduction with gentle pressure. Once reduced, a decision can be made
as to whether urgent or more elective surgery is required.
29.8 Summary
Rectal prolapse is a poorly understood condition that is challenging to treat because
of the nature of the patients affl icted with this condition and the lack of adequate
evidence to guide the most appropriate approach for an individual patient. Many
factors need to be taken into account when assessing the patient, of which the extent
of the prolapse has to be balanced against the fi tness of the patient and their preex-
isting anal control and bowel function.
Key Points
Summary of interventions for rectal prolapse
Conservative therapy•
Little role in adult rectal prolapse –
First-line treatment for prolapse in infants –
Principles of selection of “best” surgical approach•
Assessment of the patient based on: –
Sex ○
Age ○
Mobility ○
Comorbidity ○
Size of prolapse ○
Anal sphincter function ○
437
29 Rectal Prolapse
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30.1 Introduction
The condition we now recognize as pseudo-obstruction was originally described by
Zimmerman in 1930 [ 1 ] , although credit for the fi rst description is invariably attrib-
uted to the British military surgeon Sir William Heneage Ogilvie [ 2 ] . In 1948, he
described two patients who presented with abdominal pain and constipation thought
to be due to distal colonic carcinoma. At laparotomy, gross colonic distension but
no mechanical obstruction was found. In both patients, a previously unknown retro-
peritoneal neoplasm infi ltrating the prevertebral ganglia was identifi ed, leading to
the hypothesis that reduced sympathetic input to the colon played a causative role.
A subsequent series from Edinburgh in 1958 [ 3 ] described a number of patients
with motility disturbances of both the small and large bowel and fi rst used the term
“pseudo-obstruction.” Pseudo-obstruction is now used to refer solely to the clinical
picture of acute large-bowel obstruction without mechanical obstruction and is more
properly referred to as “acute colonic pseudo-obstruction” (ACPO).
Although an unusual condition, ACPO is predominantly seen in patients with
multiple comorbidities, who often have a delayed diagnosis and inappropriate treat-
ment. There is an overall mortality rate of up to 25–31%, which rises to 40–50%
when complications such as ischemia or perforation are present [ 4, 5 ] . Early recog-
nition and appropriate management are therefore essential to ensure optimal out-
come for the patient.
K. Chapple , M.B.Ch.B., Ph.D., FRCS
Colorectal Surgical Unit, Department of Surgery ,
Northern General Hospital,
Sheffi eld Teaching Hospitals NHS Foundation Trust ,
Herries Rd. , Sheffi eld, S Yorks S5 7AU , UK
e-mail: keith.chapple@sth.nhs.uk
Chapter 30
Acute Colonic Pseudo-obstruction
Keith Chapple
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