We talked with one of the Barcelona 2014 keynote speakers, Professor Evaghelos Xynos (Crete, Greece), who presented different treatment options for rectal prolapse in Barcelona.
What is known about the causes/etiology of rectal prolapse?
The condition is far more common in the aged female, and associated with chronic constipation, excessive straining at defaecation and neurological disorders affecting pelvic floor structures. Multiparity does not seem to be aetiologically related to the condition.
Also, there is no substantial evidence that overt rectal prolapse represents the terminal stage of recto-anal intussusception or other anatomical disorders associating obstructive defaecation syndrome. Rectal prolapse is common among the mentally retarded population, although no aetilogical associating has been identified. Impaired fixation of the rectum to the pelvic structures has been implicated as an additional aetilogical factor.
What are the surgical options for treating rectal prolapse?
Surgical techniques for the correction of rectal prolapse are divided to those applied transanally and those approached transabdominally. The most common transanal procedures are:
- the resection of the prolapsing rectosigmoid with colo-rectal anastomosis (Altemeier procedure)
- the mucosectomy of the prolapsing rectum with suture plication of the rectal musculature (Delorme procedure); and
- the newly introduced stapled prolapse resection (PSPR).
Transabdominal procedures are currently performed by the laparoscopic approach and include –with a great deal of variations and modifications:
- the posterior suture or prosthesis (formerly Wells procedure) rectopexy
- the anterior prosthesis rectopexy (Ripstein-like procedure)
- the resection of the redundant recto-sigmoid with colo-anal anastomosis and suture rectopexy (resection rectopexy); and
- the most recently introduced ventral prosthesis recto-colpo-rectopexy.
What are the key factors that influence a surgeons’ decision when choosing the optimal treatment (patients choice, timing, previous treatment etc)?
The main goal of any type of surgical repair should be the complete and definite reduction of the prolapse and restoration of the anorectal function. In this sense and despite the lack of substantial evidence, the transabdominal procedures are preferred to those performed transanally, because they are associated with less recurrence rate and better functional results. The latter procedures are reserved for high-risk patients with severe co-morbidities, unfit to be subjected to a major transabdominal procedure.
Of the transabdominal procedures, resection rectopexy is preferred over the prosthesis rectopexies for otherwise fit patients with severe constipation and a redundant sigmoid colon with diverticulae.
What are the typical outcomes from surgery including survival/re-operation and what is the current evidence (clinical trials, clinical paper, etc)?
According to several series and systematic reviews, transanal operations are associated with high recurrence rate, which in the case of Delorme procedure ranges form 10% to 27%, and morbidity rates of around 15%. Furthermore, functional results are impaired mostly because of reduced capacity and compliance of the rectum or neo-rectum [Lieberth et al 2009; Riansuwan et al 2010; Rethenhoefer et al 2012]. Data on the novel PSPR is limited, and the procedure is recommended for short prolapses of less than 10cm in length [Hetzer et al 2010].
According to current evidence based on limited comparative studies [Xynos et al 1999; Salomon 2002; Kairaluoma et al 2003] and some systematic reviews [Purkayastha et al 2006; Tou et al 2008; Sajid et al 2010; Caddedu et al 2012; Melton and Kwaan 2013] the laparoscopic approach for all transabdominal procedures is preferred over the open one, because it offers faster recovery, less morbidity and similar functional results. Recurrence rates after all rectopexies is very low. Postoperative functional results vary depending on the type of rectopexy. Prosthesis rectopexies are associated with severe constipation and urgency because of the increased rectal compliance [Benoist et al 2001; Madbouly et al 2002]. Resection rectopexy is superior to prosthesis or suture rectopexies, in terms of significantly less postoperative constipation [Benosit et al 2001; Fazio et al 2002; Kellocumbu et al 2002] and this is possibly attributed to the removal of the redundant sigmoid and prevention of kinking over the fixed rectum.
There are individual studies addressing the issue of i) the extent of the dissection of the rectum and the division of lateral ligaments (less recurrences, increased rate of postoperative constipation) [Tou et al 2008], ii) the necessity of posterior fixation of the rectum after mobilisation (increased recurrence rate in rectum not fixed) [Karas et al 2011], iii) type of prosthetic material (polyester or polypropylene is recommended) [Deffieux et al 2012], and iv) laparoscopic rectopexy is also safe in the elderly patients Clark et al 2012].
Ongoing are two large multicentre trials: the DeloRes Trial (Germany) that compares the transanal Delorme procedure to laparoscopic resection rectopexy and the PROSPER 2x2 Trial (UK) which compares Delorme/ Altemeier’s procedures to rectopexy/resection rectopexy, aiming to give further information and possibly some answers to the question “which procedure and to whom patient”.
Are there any new technical, device, pharmacological advances for treating the condition?
The last decade ventral prosthesis colpo-rectopexy has been very much popularised in Europe [De Hoore et al 2004, 2007; Slawik et al 2006]. The procedure, performed by the laparoscopic approach, avoids lateral and posterior mobilisation of the rectum, preventing neurologic damage in the pelvis and thus constipation, is associated with very low recurrence rate, and, by obliterating Douglas pouch, fixes anterior rectocele, prevents enterocele and improves co-existing symptoms of obstructive defaecation. According to two meta-analyses [Samaranayake et al 2010; Gouvas et al 2014] the procedure is associated with an average recurrence rate of less than 3% and significantly improves pre-existing incontinence and constipation.
Additional issues:
- Robotic-assisted laparoscopy for repair of rectal prolapse has been attempted recently, but it seems to be associated with increased recurrence rate as compared to the standard laparoscopic approach [de Hoog et al 2009; Perrenot et al 2013].
- Combined surgery, in addition to rectopexy, is recommended for total pelvic prolapse [Riansuwan et al 2010] and
- In addition to rectopexy, postoperative sacral nerve stimulation has been applied to improve sustained incontinence [Rober-Yap et al 2010].
Do you have any additional comments to make regarding your presentation?
For frail patients transanal procedures are recommended for the correction of rectal prolapse. Delorme procedure seems to be associated with limited morbidity, but recurrence is rather high.
For patients with co-existing diarrhoea or incontinence laparoscopic prosthesis rectopexy is recommended. Recurrence rate is low, but postoperative constipation is a problem in many patients. For patients with co-existing constipation or diverticular disease laparoscopic resection rectopexy has been the preferred option by many surgeons, with very low recurrence rate and less postoperative constipation.
Laparoscopic ventral prosthesis colpo-rectopexy is the novel very promising procedure, which is associated with very low recurrence rate, very low immediate postoperative morbidity and improvement of incontinence, constipation and co-existing obstructive defaecation symptoms.
