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

PH Portsmouth Colorectal rectal prolapse l non lethal miserable problem l predominantly in the elderly

PH Portsmouth Colorectal rectal prolapse l mortality l recurrence rate ~mucosal ~full thickness l post-operative function ~constipation ~incontinence l re-operation rates

PH Portsmouth Colorectal rectal prolapse methods of repair methods of repair + resection + resection abdomenal abdomenal laparoscopic combined with laparoscopic combined with fixation anal sphincter repair fixation anal sphincter repair pelvic floor repair pelvic floor repair Altemeier Altemeier perineal perineal Delorme Delorme

PH Portsmouth Colorectal Altemeier’s procedure 106 cases (19 years) mortality mortality0% morbidity morbidity 3% (local abscesses) recurrence <3% (3) functional outcome no record Altemeier Ann Surg 1971 post op

PH Portsmouth Colorectal Altemeier’s procedure pre-op preparation (1952) l Admitted 7 days preoperatively l Enemas 2 x day l Liquid or low residue diet l Sulphonomides or streptomycin etc l Hot moist applications to prolapse

PH Portsmouth Colorectal Altemeier’s procedure 63 cases (7 years) (62% day cases) mortality mortality0% morbidity morbidity 9.6% (6) anastomotic leak stenosis recurrence 4.8% (3) (21 months, median) functional outcome good incontinence / constipation improved post op Kimmins, Billingham. Dis Colon Rectum 2001

PH Portsmouth Colorectal Edmond Delorme (1900) 3 young male soldiers 1 death2 good results (11-18 months) “L’étendue de la portion muqueuse à exciser ne peut encore être précisée. L’expérience ultérieure nous fixera sur ce point d’un intérêt de premier ordre”

PH Portsmouth Colorectal rectal prolapse type of repair mean age yrs type of repair mean age yrs collected Delorme’s series collected abdominal repairs

PH Portsmouth Colorectal mortality type of operationincidence collected Delorme’s2% (5/250) collected abdominal procedures0 - 3%

PH Portsmouth Colorectal recurrence operation typemucosal full total collected Delorme’s 0%13% 13% abdominal procedures %0 - 3% 12%

PH Portsmouth Colorectal Delorme’s procedure Authoryear patients recurrence% Delorme % Swinton % Nay % Moskalenko % Uhlig % Christiansen % Monson % Abulafi % Senapati199432#412.5% Oliver % Lechaux % Thompson * 28%* *complete follow up # 75% males

PH Portsmouth Colorectal rectal prolapse l accurate / true recurrence rates ~need — large series — long follow up — use Kaplan Meier curves to measure rate of recurrence

PH Portsmouth Colorectal probability of no recurrence (Kaplan Meier plots) 1° 2°

PH Portsmouth Colorectal Delorme’s operation for rectal prolapse 50% chance of recurrence free period for patients who survive. primary operation 91 mths (CI 77-65) 8yrs secondary operation 27 mths (CI 15-39) 2yrs p p 0.004

PH Portsmouth Colorectal correlation of recurrence with length of mucosal resection l primary operations14.5cms l primary recurrences14.0cms l secondary operations10.0cms l secondary recurrences10.5cms

PH Portsmouth Colorectal Delorme’s operation No effect on rate of recurrence agesex high grade incontinence diverticular disease sphincteroplasty Watts BJS 2001 Watts BJS 2001

PH Portsmouth Colorectal Delorme’s operation continence 81 patients pre-oppost-op pre-oppost-op 10% 35% 10% 35%

PH Portsmouth Colorectal Delorme’s operation continence; pad usage pre-op63% (51/81) post-op31% (25/81) 32 stopped 19 continued pads 7 started

PH Portsmouth Colorectal constipation type of operation incidence collected Delorme’s not a problem collected Altemeier not a problem collected abdominal procedures %

PH Portsmouth Colorectal perineal operations for rectal prolapse safe technically simple functional results satisfactory

PH Portsmouth Colorectal perineal operations for rectal prolapse first choice for the: elderly and frail young women young men constipated patients

PH Portsmouth Colorectal Delorme’s procedure with sphincter repair no’s of patients l Delorme (1900)1 l Adair (1962)19 l Nay (1972)30 l Uhlig (1979)20 l Christiansen (1987)11 l Thompson (1994)14 l Lechaux (1995)39

PH Portsmouth Colorectal Delorme’s operation for rectal prolapse functional results constipation Berman ( ) ~ used Delorme’s procedure to treat constipation Plusa (1995) ~ showed a decrease in rectal compliance after Delorme’s

PH Portsmouth Colorectal Delorme’s operation improves incontinence

PH Portsmouth Colorectal outcome of patients in this series

PH Portsmouth Colorectal Altemeier’s procedure 20 cases (2½) years) mortality mortality 5% (1) morbidity morbidity 5% (1) (pelvic haematoma) recurrence ? 0%? (26 months, mean) functional outcome 90% improved continence Johansen, Wesner, Jagelman. Dis Colon Rectum 1993 post op

PH Portsmouth Colorectal Altemeier’s procedure 72 patients 10 yrs mortality mortality0% morbidity morbidity 4% (3) anastomotic leak recurrence 5.3% (4) (48 months, mean) functional outcome improved continence Ramanujam Dis Colon Rectum 1994 post op

PH Portsmouth Colorectal Altemeier’s procedure 20 cases (2½) years) mortality mortality 5% (1) morbidity morbidity 5% (1) (pelvic haematoma) recurrence ? 0%? (26 months, mean) functional outcome 90% improved continence Johansen, Wesner, Jagelman. Dis Colon Rectum 1993 post op

PH Portsmouth Colorectal probability of no recurrence (Kaplan Meier plots) 1st 2nd 3rd

PH Portsmouth Colorectal Delorme’s operation continence 81 patients 89% static or improved

PH Portsmouth Colorectal Delorme’s operation decreases constipation low rectal compliance improved evacuation removal of colonic break improved rectal filling

PH Portsmouth Colorectal perineal operations for rectal prolapse higher rate of recurrence can this be improved: better technique better selection of patients

PH Portsmouth Colorectal Delorme’s operation varying recurrence rates age/sex l casemixseverity of prolapse weakness of pelvic floor l completeness of follow up l high death rate in elderly patients