476 Ann. Ital. Chir., 87, 5, 2016

Perineal stapled prolapse resection (PSPR) for external rectal prolapse in high morbidity patients Ann. Ital. Chir., 2016 87: 476-480

pii: S0003469X16025586

Pervenuto in Redazione Marzo 2016. Accettato per la pubblicazioneMaggio 2016.Correspondence to: Matteo Maternini, MD, UOC Chirurgia Generale,Istituti Clinici Zucchi, Via Bartolomeo Zucchi 24, 20900 Monza - Italy(e-mail: matteo.maternini@live.it)

Matteo Maternini, Angelo Guttadauro, Nicoletta Pecora, Francesco Gabrielli

UOC Chirurgia Generale, Istituti Clinici Zucchi, Monza Italy

Perineal stapled prolapse resection (PSPR) for external rectal prolapse in high morbidity patients

AIM: To demonstrated the efficacy an safety of a perineal stapled approach to treat the protrusion of the entire layer of therectum outside the anus in high morbidity patients.MATHERIALS OF STUDY: From February 2012 to april 2013, 7 patients (all female, mean age 74,2 years, range 48-88)were operated in our unit with perineal stapled prolapsed resection (PSPR) approach for a full thickness external rectalprolapse.RESULTS: The duration of hospitalization was 3 days and the follow-up period was 18 months. There were no intraoperativecomplications and all patients had a bowel movement within 3 days of surgery. There was no mortality. None patientssuffered of incontinence. Two patients (28,5%) had a recurrence and proctorragy after 18 months.DISCUSSION: PSPR can be considered among perineal approaches for the treatment of full-thickness rectal prolapse. Thereported rate of minor complications is low. No major complications have been described. Functional outcome is good, withmarked improvement in both continence and constipation.CONCLUSIONS: These results are better than those reported for other perineal procedures, although no randomized trials haveyet been published. A multicenter study is needed to better evaluate the indications for and the outcome AFTER PSP.

KEY WORDS: Morbidity patients, Perineal stapled prolapse resection, Rectal prolapse

Many surgical approaches for prolapsed have beendescribed with the aim of eradicating the external pro-lapsing segment and improving continence and consti-pation.Actually the choice is between the abdominal approach(rectopessy) or perineal approach (Altemier’s or Delorme’sprocedure) 2.According to the guidelines of the American Society ofColorectal Surgeons, patients with a rectal prolapsed whoare not candidates for an abdominal operation may betreated with a perineal approach.Although comparative data suggest that perineal opera-tions are associated with a higher recurrence rate 3, recentanalysis which score-matched patients for clinical riskfound a minimal difference in outcome between abdom-inal and perineal procedure 4..Historically the principal perineal procedures performedare the Delorme’s operation and the Altemeier perineal

Introduction

The protrusion of the entire layer of the rectum outsidethe anus, is an important cause of disability, especiallyin elderly women (80-90% of patients) where it is fre-quently associated with fecal incontinence 1.The incidence of complete external rectal prolapse isabout 1-2% in the population over 70.

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Ann. Ital. Chir., 87, 5, 2016 477

Perineal stapled prolapse resection (PSPR) for external rectal prolapse in high morbidity patients

rectosigmoidectomy with a reported recurrences ratesbetween 25 and 38% overall 5,6.Recently, Scherer et al, presented a new perineal surgi-cal approach, perineal stapled prolapsed resection (PSPR),for the treatment of a full thickness external rectal pro-lapsed. As described, use of the Contour® Transtar™stapler (STR5G; Ethicon Endo-Surgery, Cincinnati,Ohio, USA) allows safe transanal resection of the rectalprolapsed.A recent report 7 has shown that this technique is asso-ciated with minimal morbidity and good functionalshort-term outcome.We report our preliminary results of the PSPR techniquein the resection of external rectal prolapsed.

Materials and Methods

From February 2012 to April 2013, 7 patients (all female,mean age 74,2 years, range 48-88 ) were operated in ourunit with PSPR approach for a full thickness external rec-tal prolapse.All patients are evaluated at risk for abdominal surgerywith an American Society of Anesthesiologists (ASA) score3.The length of the rectal external prolapsed was comprisedbetween 2,5 and 5,5 cm (Table I).A colonoscopy and colpocistodefecografy were performed.The day before surgery a bowel preparation with two clis-ma feet was performed.At the start of operation a prophylactic antibiotic dosewith a combination of cephalosporin (1g) and metron-idazole (500mg) was administrated and continued for 24hours.All patients were operated under spinal anesthesia. Follow-up visits were performed at 7 days, 1 month, 3month, 6 month, 12 month and 18 month after surgery.

SURGICAL TECHNIQUE

The patient is placed in a lithotomy position. To freethe pouch of Douglas from any deep enterocele, a slightTrendelemburg position was chosen. The prolapse was

completely pulled out and fixed by Allis clamps placedat its verge. To exclude the entrapment of any intraperi-toneal organ a very careful bi-manual examination wasperformed. The prolapse was axially cut at the threeo’clock position with a linear stapler (Proximate® Linearcutter 75 mm, Ethicon Endo-Surgery) (Fig. 1). The sta-ple line ended 2 cm from the dentate line. The prolapse

TABLE I - Population

Patients Age ASA score BMI Prolapse Length(cm)

1 88 3 28 32 78 3 29 2,53 77 3 31 44 77 3 27 5,55 71 3 28 4,56 48 3 20 37 81 3 26 3,5

Fig. 1: The prolapsed was axially cut at the three o’clock positionwith a linear stapler.

Fig. 2: Average we utilized 1-2 Proximate® Linear cutter 75 mmand 6-8 CCS 30 Contour® Transtar™.

Fig. 3: After completing the resection, the anal mucosa and the neo-rectum fell back into place spontaneously.

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478 Ann. Ital. Chir., 87, 5, 2016

was resected continuously counterclockwise by the curvedCCS 30 Contour® Transtar™ and parallel to the dentateline. Average we utilized 1-2 Proximate® Linear cutter 75mm and 6-8 CCS 30 Contour® Transtar™ (Fig. 2) .After completing the resection, the anal mucosa and theneorectum fell back into place spontaneously (Fig. 3).Absorbable monofilament sutures were performed tostrengthen the anastomosis and ensure haemostasis. All thesurgical specimens were sent for histological examination.

Results

The PSPR was successfully completed with a medianoperative time of 63 min (range 48-95 min) and a medi-an use of 6 cartridges (range 4-9 cartridges).

The median length of resected bowel was 7,5 cm (range5-11 cm).All patients were investigated for proctorragia, pain (eval-uated by VAS score) and constipation (Table III-IV). Onhistology rectal wall and peritoneal reflection (Douglaspouch) were present in all casesThe duration of hospitalization was 3 days in all patientsand the follow-up period was 18 months.There were no intraoperative complications and allpatients had a bowel movement within 3 days of surgery.There was no mortality. None patients suffered of incon-tinence.Two patients(28,5%) had a recurrence and proctorragyafter 18 months. We didn’t treat it because the prolapsedwere asymptomatic and proctorragy irrelevant and wellsupported.Al the patients reported improvement of constipation(Table IV).

Discussion

Rectal prolapse is a disabling condition often affectingelderly women. In general, two different approaches canbe distinguished in the surgical treatment of rectal pro-lapsed; the abdominal and the perineal approach.Perineal procedures are recommended for patients, whichmay be not suitable for transabdominal rectopexy becauseof concomitant cardiovascular or pulmonary diseases. Inthe past, the majority of patients undergoing perinealapproach were treated with either Delorme’s or Altemeierprocedure 4,5. The use of a stapling device, as alterna-tive to the Altemeier procedure, is in debate for decades.In 2008, Scherer et al. presented a new perineal surgi-cal approach, the so-called perineal stapled prolapse resec-tion, for the treatment of external rectal prolapse 8. Theuse of the Contour® Transtar™ stapler (Ethicon Endo-Surgery, Norderstedt, Germany) permits safe transanalresection of external rectal prolapse by a technical mod-ification of the Altemeier procedure and allows resectionof rectal intussusceptions under direct view. There arelimited guidelines to show which procedure is superiorin terms of safety, recurrence rate or functional outcome3.

TABLE II - Results

Patients Prolapse length Operation time Recurrence(cm) (min) (18 months)

1 3 60 No2 2,5 70 Yes3 4 70 Yes4 5,5 48 No5 4,5 40 No6 3 95 No7 3,5 60 No

TABLE III - Symptoms

Patients VAS VAS Rectorragy RectorragyPre-op Post-op Pre-op post-op

1 7 0 Present No2 8 2 Present Present3 6 2 Present Present4 7 0 Present No5 8 0 Present No6 7 0 Present No7 7 0 Present No

TABLE IV - Wexner Score and Follow-up

Patients Wexner Constipation Wexner Constipation Wexner Constipation 18 months AverageScore Pre-op Score Post-op Score Post-op Improvement Improvement

(6 months) (18 months) (%) (%)

1 15 9 5 66.6 63.4 ± 10.62 21 12 5 76.23 23 10 10 56.54 11 7 3 72.75 8 7 3 62.56 17 6 6 64.77 9 7 5 44.4

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There are several reports of the STARR(stapled transanalrectal resection) procedure, performed both with circu-lar or Contour stapler for mucosal rectal prolapse orinternal prolapse with a small rectal protrusion of up to5 cm 9,10. In our preliminary study, the PSPR procedureappears safe, technically easy and quick to perform.When it is decided that the patient’s condition is moresuited to a perineal operation, it is known that Delorme’sprocedure can have a high recurrence rate ranging up to37 % after only short follow-up 5, whereas Altemeier’soperation has a lower reported recurrence rate(11,12).Our recurrence rate (28.5 %) is consistent withother reported PSPR literature quoting a 19.7% recur-rence rate after 3 years of follow-up 13,14. It is important that there should not be too much tis-sue incorporated into the Contour_ TranstarTM stapler,particularly on the posterior wall where both the rectalwall and the mesorectum are divided by the stapler. Thisnecessitates the performance of smaller stapler stepswhere the jaws of the stapler must be able to be easilyclosed.The median operating time for the performance of PSPRis less than that recorded for either Delorme’s or theAltemeier’s procedures 15,16. The duration of surgery andthe number of stapler cartridges required is dependentupon the prolapse length and weight. From a technicalstandpoint, PSPR results in a wider anastomosis than anAltemeier resection where the technique as used limitsthe risk of the staple line spiraling away from the oper-ator.The continuing development of surgical techniques forprolapse management is evidence that the choice of oper-ation for individual patients is still a matter of debate.Although laparoscopic and robotic abdominal rectopexyis being increasingly used, many authors still considerperineal rectosigmoidectomy to be the operation ofchoice for elderly and high-risk patients with rectal pro-lapse exceeding 5 cm 17-19. The main drawbacks of PSPRare the impossibility to make a visual control on smallbowel and vagina during stapling, its high cost and therelatively limited prolapse length that can be resected.

Conclusions

PSPR can be considered among perineal approaches forthe treatment of full-thickness rectal prolapse. Thereported rate of minor complications is low. No majorcomplications have been described. Functional outcomeis good, with marked improvement in both continenceand constipation. The recurrence rate does not appearto be superior to other methods. It is however necessarya longer follow-up. These results are better than thosereported for other perineal procedures, although no ran-domized trials have yet been published. A multicenterstudy is needed to better evaluate the indications for andthe outcome after PSP.

Ann. Ital. Chir., 87, 5, 2016 479

Perineal stapled prolapse resection (PSPR) for external rectal prolapse in high morbidity patients

Riassunto

Scopo di questo studio retrospettivo è stato quello didimostrare l’efficacia, la sicurezza e la relativa facilità diesecuzione dell’approccio perineale con stapler nel trat-tamento del prolasso totale di retto.Nel periodo compreso tra febbraio 2012 ed aprile 2013abbiamo sottoposto 7 pazienti ,affette da prolasso totaledi retto, ad intervento di resezione perineale con stapler.Tutte le pazienti sono state dimesse in III° giornata post-operatoria dopo ripresa del transito. Il follow-up è statodi 18 mesi.Non sono state registrate complicanze intraoperatorie ne’vi è stata mortalità. Non ci sono stati problemi di incon-tinenza nel post-operatorio.A 18 mesi di distanza abbiamo registrato due episodi direcidiva associati a proctorragia (28,5%). Entrambi i casinon hanno richiesto un reintervento a causa della scar-sità dei sintomi, ben tollerati da entrambe le pazienti.Concludendo possiamo affermare che, nella nostra espe-rienza, l’approccio perineale con stapler al prolasso tota-le di retto, risulta essere una metodica sicura, relativa-mente facile da eseguire e con un tasso di complicanzecomparabile a quello riportato in letteratura ed inferio-re a quello delle altre metodiche di approccio perineale.Le limitazioni di tale metodica sono principalmentedovute alla lunghezza e alla spessore della parete prolas-sata.Sicuramente per validare la procedura e le sue indica-zioni è auspicabile che venga condotto uno studio mul-ticentrico randomizzato.

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480 Ann. Ital. Chir., 87, 5, 2016

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