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562 Strategy for Selection of Type of Operation for Rectal Prolapse Based on Clinical Criteria [2004년 1월 DCR] 2011-12-23 1641
 
A. J. Brown, M.B., Ch.B., J. H. Anderson, M.D., R. F. McKee, M.D., I. G. Finlay, M.B., Ch.B.
Department of Coloproctology, Glasgow Royal Infirmary, Glasgow, United Kingdom
 
PURPOSE: Reports of outcome after surgery for rectal prolapse predominantly relate to single operative procedures. A single surgical operation is not appropriate for all patients with rectal prolapse. We describe a selective policy based on clinical criteria.
METHODS: Patients were offered surgery according to the following broad clinical protocol. Those who were unfit for abdominal surgery had a perineal operation. The remainder had a suture abdominal rectopexy. A sigmoid resection was added for patients in whom incontinence was not a predominant symptom.
RESULTS: Surgery was performed in 159 patients. Of these, 57 had a perineal operation, 65 had fixation rectopexy, and 37 had resection rectopexy. There were no in-hospital deaths, and major complications occurred in five patients (3.5 percent). Minimum follow-up was 3 years. Of the 143 patients with long-term follow-up, recurrence occurred in 7 (5 percent). Constipation increased from 41 to 43 percent (59–61/143) and incontinence decreased from 43 to 19 percent (61 to 27/143).
CONCLUSIONS: A selective policy has improved outcome compared with reports of a single operation. Future studies might consider an objective method of selecting the type of operation for rectal prolapse.
 
More than 100 different operative procedures have been described for rectal prolapse. Broadly, these are classified as abdominal or perineal, according to the route of access. Abdominal operations involve dissection and fixation of the rectum and may include sigmoid/colonic resection. Perineal operations may include repair of the pelvic floor/anal sphincters with or without bowel resection. Although there are proponents for each approach, there have been few comparative trials, and to date there are no guidelines as to which operation should be used in any given clinical situation.
 
During the period of this study, we selected the operation for patients with rectal prolapse based on
simple clinical criteria. Elderly or frail patients are offered a perineal procedure: fit patients have an abdominal operation irrespective of age. Of the latter group, those in whom the principal symptom is fecal incontinence are treated by rectopexy without colonic resection; those with no incontinence are treated by resection rectopexy. We report the outcome using these criteria.
 
DISCUSSION
The literature with regard to the surgery of rectal prolapse predominantly reports outcomes after a
single, operative approach, making the assumption that one operation is suitable for all patients with the
condition. We have developed a selective policy for the selection of type of operation for patients with
rectal prolapse.
 
Historically, the most widely used operation for rectal prolapse in the United Kingdom has been rectopexy, which involves dissection of the rectum to the pelvic floor with fixation using foreign material,
such as ivalon or, more recently, marlex. The operation is highly effective in removing the prolapse
and preventing recurrence (0–4 percent) but produces the complication of severe constipation, which
is difficult to treat in up to 50 percent of patients. Several putative explanations for this have been proposed, including denervation of the rectum after dissection and division of the lateral ligaments, loss of compliance of the rectum caused by foreign-fixation material, creation of a redundant sigmoid loop producing partial obstruction, or an underlying hindgut neuropathy. In an attempt to reduce the risk of postoperative constipation, resection of the redundant sigmoid colon has been advocated and has been shown in two small, prospective, randomized trials to be safe and to reduce postoperative constipation but perhaps with an increased risk of incontinence. It also has been shown that it is unnecessary to use foreign material to fix the rectum, thereby reducing the risk of infection and altered rectal compliance. Based on this evidence, we developed our strategy for the selection of an abdominal operation for patients with rectal prolapse. All patients had a suture rectopexy without the use of fixation material. Those patients in whom the predominant symptom was constipation had a sigmoid resection, but this was avoided in patients with incontinence. Despite these broad guidelines, there were patients who were not treated according to the protocol. This may have been because patients frequently have both constipation and incontinence. It also may reflect the variability in clinical decision making despite a broad protocol.
 
Perineal operations for rectal prolapse have the advantage that they are less invasive for unfit patients
but have a high recurrence rate. This is unfortunate because the postoperative functional results, particularly with regard to constipation, are better than those reported after abdominal rectopexy. Our management strategy limited perineal operations to those who were unfit for an abdominal approach.
 
In the present study, the use of this selective policy was safe and effective. There were no in-hospital
deaths and few complications. The overall recurrence rate was 5 percent but was significantly higher in the perineal group. This may limit the use of perineal operations as the initial surgical treatment for rectal
prolapse to those patients who are unsuitable for an abdominal operation. Advocates for the perineal approach would counter with the view that the operation can be easily reperformed in the event of recurrence. Furthermore, it is possible in this series that patients who had a perineal procedure may have had a more severe prolapse than the younger patients who had an abdominal procedure. The availability of minimally invasive laparoscopic operations, which were not used in this series, may further extend the indications for the abdominal approach.
 
The introduction of our selective policy was predominantly designed to improve postoperative function.
Constipation increased by only 2 percent compared with the large increases reported after fixation
rectopexy and is probably attributable to the selective use of sigmoid colon resection, avoidance of
foreign-fixation material, and preservation of the lateral ligaments. Incontinence was markedly reduced in the present series from 24 to 19 percent. This may be explained in part by the avoidance of sigmoid resection in patients who had incontinence before surgery and plication of the anal sphincter at the perineal operations. Other explanations include increased anal sphincter pressure, improved rectal and anal canal sensation, and restoration of the rectoanal inhibitory reflex as a consequence of relief of the pressure and stretch of the rectal prolapse.
 
Although many patients had other investigations, including anorectal physiology, pudendal nerve motor
terminal latency, and colonic transit studies, these were not used in the strategy for the selection of the
operative procedure. Future studies may attempt to develop a selection strategy based on one or more of these investigations.
 
CONCLUSIONS
Overall, the results of the present study show an improvement over reports of a single technique.
1. Recurrence rates are better than those reported for single series of perineal operations.
2. Constipation rates are better than those reported for fixation rectopexy.
3. Incontinence rates are better than those reported after the use of resection rectopexy.
 
Patients with rectal prolapse show considerable variability with regard to extent of prolapse, degree of anal sphincter and pelvic floor neuropathy, degree of hindgut neuropathy, and delay in colonic transit. Consequently, there is probably no single operation that is suitable for all patients and no operation that will produce complete resolution of all symptoms. We have proposed a compromise based on simple clinical criteria that seem to have improved overall outcome compared with series of individual operations. Further study, ideally by randomized, controlled trials, is required to determine whether selection can be based on more objective criteria.