PH Portsmouth Colorectal ACPGBI M62 Meeting Huddersfield April 2005 Perineal Options for Rectal Prolapse M.R. Thompson

PHPortsmouth Colorectal

ACPGBI M62 MeetingACPGBI M62 MeetingHuddersfield April 2005Huddersfield April 2005

Perineal Options for Rectal ProlapsePerineal Options for Rectal Prolapse

M.R. Thompson


rectal prolapserectal prolapse

non lethal miserable problemnon lethal miserable problem predominantly in the elderlypredominantly in the elderly



mortalitymortality recurrence raterecurrence rate

~ mucosalmucosal~ full thicknessfull thickness

post-operative functionpost-operative function~ constipationconstipation~ incontinenceincontinence

re-operation ratesre-operation rates


rectal prolapserectal prolapse methods of repairmethods of repair

++ resection resection

abdomenalabdomenal laparoscopiclaparoscopic combined with combined with

fixationfixation • anal sphincter repair • anal sphincter repair

• • pelvic floor repairpelvic floor repair AltemeierAltemeier

perinealperineal

Delorme Delorme


Altemeier’s procedureAltemeier’s procedure106 cases (19 years)106 cases (19 years)

mortalitymortality 0%0%

morbiditymorbidity 3% (local abscesses)3% (local abscesses)

recurrencerecurrence <3% (3)<3% (3)

functional functional outcomeoutcome

no recordno record

Altemeier Ann Surg 1971

post op


Altemeier’s procedureAltemeier’s procedurepre-op preparation (1952)pre-op preparation (1952)

Admitted 7 days preoperativelyAdmitted 7 days preoperatively

Enemas 2 x dayEnemas 2 x day

Liquid or low residue dietLiquid or low residue diet

Sulphonomides or streptomycin etcSulphonomides or streptomycin etc

Hot moist applications to prolapseHot moist applications to prolapse


Altemeier’s procedureAltemeier’s procedure63 cases (7 years)63 cases (7 years)(62% day cases)(62% day cases)


morbiditymorbidity 9.6% (6) anastomotic leak 9.6% (6) anastomotic leak stenosisstenosis

recurrencerecurrence 4.8% (3) (21 months, median)4.8% (3) (21 months, median)


goodgoodincontinence / constipation incontinence / constipation improvedimproved

post op

Kimmins, Billingham. Dis Colon Rectum 2001


Edmond Delorme (1900)Edmond Delorme (1900)

3 young male soldiers3 young male soldiers

1 death1 death 2 good results (11-18 2 good results (11-18 months)months)

““L’étendue de la portion muqueuse à L’étendue de la portion muqueuse à exciser ne peut encore être précisée. exciser ne peut encore être précisée. L’expérience ultérieure nous fixera sur L’expérience ultérieure nous fixera sur ce point d’un intérêt de premier ordre”ce point d’un intérêt de premier ordre”



type of repairtype of repair mean age mean age yrsyrs

collected Delorme’s seriescollected Delorme’s series 70 - 75 70 - 75

collected abdominal repairscollected abdominal repairs 59 - 65 59 - 65


mortalitymortality

type of operationtype of operation incidenceincidence

collected Delorme’scollected Delorme’s 2% (5/250)2% (5/250)

collected abdominal procedurescollected abdominal procedures 0 - 3%0 - 3%


recurrencerecurrence

operation typeoperation type mucosalmucosal full full total total

collected Delorme’scollected Delorme’s 0% 0% 13%13% 13% 13%

abdominal proceduresabdominal procedures 8 - 31% 8 - 31% 0 - 3% 12%0 - 3% 12%


Delorme’s procedureDelorme’s procedureAuthorAuthor year patients recurrenceyear patients recurrence %%DelormeDelorme 19001900 33 00 0%0%SwintonSwinton 19601960 1919 66 30%30%NayNay 19721972 3434 77 21%21%MoskalenkoMoskalenko 19731973 1010 00 0%0%UhligUhlig 19791979 4444 33 10%10%ChristiansenChristiansen 19811981 1212 22 16%16%MonsonMonson 19861986 2727 22 7%7%AbulafiAbulafi 19901990 2222 11 4%4%SenapatiSenapati 19941994 32#32# 44 12.5%12.5%OliverOliver 19941994 4141 99 22%22%LechauxLechaux 19951995 8585 1111 13.5%13.5%ThompsonThompson 20012001 113*113* 28%* 28%**complete follow up*complete follow up# 75% males# 75% males



accurate / true recurrence ratesaccurate / true recurrence rates~ needneed

—large serieslarge series—long follow uplong follow up—use Kaplan Meier curves to use Kaplan Meier curves to

measure rate of recurrence measure rate of recurrence


probability of no recurrence probability of no recurrence (Kaplan Meier plots)(Kaplan Meier plots)

Time after surgery (months)

14413212010896847260483624120

Pro

babi

lity

of

no-r

ecu

rre

nce

1.0

.8

.6

.4

.2

1°2°


Delorme’s operation for rectal prolapseDelorme’s operation for rectal prolapse

50% chance of recurrence free period50% chance of recurrence free period for for patients who survive. patients who survive.

primary operation 91 mths (CI 77-65) 8yrsprimary operation 91 mths (CI 77-65) 8yrs

secondary operationsecondary operation 27 mths (CI 15-39) 27 mths (CI 15-39) 2yrs2yrs

p 0.004 p 0.004


correlation of recurrence with correlation of recurrence with length of mucosal resectionlength of mucosal resection

primary operationsprimary operations 14.5cms14.5cms primary recurrencesprimary recurrences 14.0cms14.0cms secondary operationssecondary operations 10.0cms10.0cms secondary recurrencessecondary recurrences 10.5cms10.5cms


Delorme’s operationDelorme’s operation

No effect on rate of recurrenceNo effect on rate of recurrence

ageage

sexsex

high grade incontinencehigh grade incontinence

diverticular diseasediverticular disease

sphincteroplasty sphincteroplasty

Watts BJS 2001 Watts BJS 2001



continencecontinence

81 patients81 patients

pre-oppre-op post-oppost-op

10%10% 35% 35%


Delorme’s operationDelorme’s operationcontinence; pad usagecontinence; pad usage

pre-oppre-op 63% (51/81)63% (51/81)

post-oppost-op 31% (25/81)31% (25/81)

32 stopped32 stopped

19 continued pads19 continued pads

7 started7 started


constipationconstipation

type of operationtype of operation incidence incidence

collected Delorme’scollected Delorme’s not a problem not a problem

collected Altemeier collected Altemeier not a problem not a problem

collected abdominal procedurescollected abdominal procedures 25 - 47%25 - 47%


perineal operations for perineal operations for rectal prolapserectal prolapse

safesafe

technically simpletechnically simple

functional results satisfactoryfunctional results satisfactory


perineal operations for perineal operations for rectal prolapserectal prolapse

first choice for the:first choice for the:

elderly and frailelderly and frail

young womenyoung women

young menyoung men

constipated patientsconstipated patients


Delorme’s procedure with Delorme’s procedure with sphincter repairsphincter repair

no’s of patientsno’s of patients Delorme (1900)Delorme (1900) 11 Adair (1962)Adair (1962) 1919 Nay (1972)Nay (1972) 3030 Uhlig (1979)Uhlig (1979) 2020 Christiansen (1987)Christiansen (1987) 1111 Thompson (1994)Thompson (1994) 1414 Lechaux (1995)Lechaux (1995) 3939


Delorme’s operation for rectal prolapseDelorme’s operation for rectal prolapse

functional resultsfunctional results

constipationconstipation

Berman (1985 + 1990)Berman (1985 + 1990)

~ used Delorme’s procedure to treat constipationused Delorme’s procedure to treat constipation

Plusa (1995)Plusa (1995)

~ showed a decrease in rectal compliance after showed a decrease in rectal compliance after Delorme’sDelorme’s



improves incontinenceimproves incontinence


outcome of patients in this seriesoutcome of patients in this series

died with no recurrence

alive with recurrence died with

recurrence

alive with no recurrence

no follow up

13%

43%

3%12%

29%


Altemeier’s procedureAltemeier’s procedure20 cases (220 cases (2½) years)½) years)

mortalitymortality 5% (1)5% (1)

morbiditymorbidity 5% (1) (pelvic haematoma)5% (1) (pelvic haematoma)

recurrencerecurrence ? 0%? (26 months, mean)? 0%? (26 months, mean)


90% improved continence90% improved continence

Johansen, Wesner, Jagelman. Dis Colon Rectum 1993

post op


Altemeier’s procedureAltemeier’s procedure72 patients 10 yrs72 patients 10 yrs


morbiditymorbidity 4% (3) anastomotic leak4% (3) anastomotic leak

recurrencerecurrence 5.3% (4) (48 months, mean)5.3% (4) (48 months, mean)


improved continenceimproved continence

Ramanujam Dis Colon Rectum 1994

post op


Altemeier’s procedureAltemeier’s procedure20 cases (220 cases (2½) years)½) years)

mortalitymortality 5% (1)5% (1)

morbiditymorbidity 5% (1) (pelvic haematoma)5% (1) (pelvic haematoma)

recurrencerecurrence ? 0%? (26 months, mean)? 0%? (26 months, mean)


90% improved continence90% improved continence

Johansen, Wesner, Jagelman. Dis Colon Rectum 1993

post op


probability of no recurrence probability of no recurrence (Kaplan Meier plots)(Kaplan Meier plots)

Time after surgery (months)

14413212010896847260483624120

Pro

babi

lity

of no

-recu

rrenc

e1.0

.9

.8

.7

.6

.5

.4

.3

1st

2nd

3rd



continencecontinence

81 patients81 patients

89%89%

static or improvedstatic or improved



decreases constipationdecreases constipation

low rectal compliancelow rectal compliance

improved evacuationimproved evacuation

removal of colonic breakremoval of colonic break

improved rectal fillingimproved rectal filling


perineal operations for perineal operations for rectal prolapse rectal prolapse

higher rate of recurrencehigher rate of recurrence

can this be improved:can this be improved:

better techniquebetter technique

better selection of better selection of patientspatients



varying recurrence ratesvarying recurrence rates

age/sexage/sex casemixcasemix severity of prolapseseverity of prolapse

weakness of pelvic floorweakness of pelvic floor completeness of follow upcompleteness of follow up high death rate in elderly patientshigh death rate in elderly patients

Documents

PH Portsmouth Colorectal ACPGBI M62 Meeting Huddersfield April 2005 Perineal Options for Rectal Prolapse M.R. Thompson