Perineal rectosigmoidectomy on treatment of rectal procidentia: analysis of 48 cases

ORIGINAL ARTICLE

Perineal rectosigmoidectomy on treatment of rectal procidentia: analysis of 48 cases

Bruno Amaral Medeiros^I, Leonardo Estenio Iezzi^I, Marley Ribeiro Feitosa^I, Rogério Serafim Parra^II, Ana Luiza Normanha Ribeiro de Almeida^II, Raphael Gurgel de Carvalho^I, Jose Joaquim Ribeiro da Rocha^III, Omar Feres^IV

^IMD; Resident of the Division of Coloproctology of the Department of Surgery and Anatomy of the Ribeirão Preto Medical School at University of São Paulo (USP) – Ribeirão Preto (SP), Brazil

^IIMD; Research fellow of the Division of Coloproctology of the Department of Surgery and Anatomy of Faculdade de Medicina de Ribeirão Preto da USP – Ribeirão Preto (SP), Brazil

^IIIMD; PhD; Head of the Division of Coloproctology of the Department of Surgery and Anatomy of the Faculdade de Medicina de Ribeirão Preto da USP – Ribeirão Preto (SP), Brazi

^IVMD; PhD; Professor of Division of Coloproctology of the Department of Surgery and Anatomy of the Faculdade de Medicina de Ribeirão Preto da USP – Ribeirão Preto (SP), Brazil

^{Correspondence to}

ABSTRACT

OBJECTIVE: To evaluate results obtained in 48 cases of perineal rectosigmoidectomy in patients with rectal procidentia.

METHODS: 48 medical records of patients undergoing PRS were analyzed, retrospectively.

RESULTS: Before surgery, 44 patients (77.1%) reported complaints of anal mass and rectal bleeding was reported 13 times (22.8%). The period of hospitalization was 3.91 days (2 to 12 days). Women were the majority (85.4%). The mean age was 73.8 years (49 to 101 years). The average time of surgery was 72 minutes (40 to 90 minutes). Mechanical anastomosis was performed in 72.9% and manual in 27.1%. Among the 12 (25%) patients with fecal incontinence, continence was achieved in 2 cases. Postoperative complications occurred in five cases – 10.5% (two pneumonia and three anastomotic leakages). Recurrence was verified in four patients (8,3%). There were no deaths related to the procedure.

CONCLUSION: Perineal rectosigmoidectomy is a good surgical option for rectal procidentia, with low morbidity and mortality, low recurrence rate and short hospitalization length.

Keywords: colectomy; perineum; rectal prolapse.

RESUMO

OBJETIVO: Avaliar o resultado de 48 casos de procidência retal submetidos a retossigmoidectomia perineal.

MÉTODO: Análise retrospectiva de 48 prontuários de pacientes submetidos a retossigmoidectomia perineal.

RESULTADO: Antes da cirurgia, 44 pacientes (77,1%) queixavam-se de "massa na região anal" e sangramento transretal foi relatado em 13 (22,8%) casos. O tempo de internação médio foi de 3,91 dias (2 a 12 dias). O gênero feminino prevaleceu na amostra (85,4%). A idade média foi 73,8 anos (49 a 101 anos). O tempo médio de cirurgia foi 72 minutos (40 a 90 minutos). Optado por anastomose mecânica em 72,9% dos casos e manual em 27,1%. Entre os 12 (25%) pacientes com incontinência fecal, foi alcançada continência em 2 casos. Complicações pós-operatórias ocorreram em cinco casos – 10,5% (duas pneumonias e três deiscências de anastomose). Recorrência foi verificada em quatro pacientes (8,3%). Não houve óbito relacionado ao procedimento.

CONCLUSÃO: A retossigmoidectomia perineal é uma boa opção cirúrgica para procidência retal, com baixa morbimortalidade, baixo índice de recorrência e curta internação hospitalar.

Palavras-chave: colectomia; períneo; prolapso retal.

INTRODUCTION

Rectal procidentia (RP) is characterized by protrusion of rectum through the anus with all of its layers¹. Although more than one hundred surgical procedures were described so far for the treatment of RP, the ideal treatment method still remains unclear².

RP occurs at the extremes of age^1,3. In the pediatric patients, it occurs with an equal sex distribution and correlates to collagen-associated disorders. In the adult population, incidence is after the fifth decade and women are most affected – about 80 to 90% of patients^3,4. It happens, indeed, due to acquired loss of collagen strength, included here pelvic support weakness, associated with aging, notably in women.

The symptoms of RP could mimic the warning signs for rectal cancer: mass, change in bowel habits or even bleeding and tenesmus. Loss of control of stool, because of strechting of the sphincter muscles and pudendal nerves, may occur in advanced stages⁵. These conditions are associated with deterioration of quality of life.

Non operative-treatment has been chosen sometimes, since many patients are elderly or carry high operative risk, but with poor results when isolated therapy⁵. Biofeedback, although, has been used with satisfactory results improving postoperative results and function⁶.

According to the route of access, the operative treatment is classified as "abdominal"^7-9 or "perineal"^10-12. The perineal access has the clear vantage of, avoiding laparotomy, exposing patients (usually elderly) to less surgery damage, and postoperative complications (risks of a general anesthesia and postoperative pain, for example). Recently laparoscopic sigmoidectomy and rectopexy has appeared as therapeutic modality¹³.

The Altemeier procedure consists in an excision of rectum and a portion of sigmoid colon, full-thickness¹⁴. This technique, actually described in the 19^th century by Mickulicz¹⁵, has been more associated with Altemeier since 1971¹⁴. The short operating time, the fact of only spinal cord anesthesia required (in despite of general anesthesia), the short length of hospital stay and good results corroborate the increased indication of this procedure¹⁶.

PURPOSE

To evaluate 48 cases of perineal rectosigmoidectomy (Altemeier procedure, PRS) in patients with full-thickness RP, preoperatively, on short and long term after surgery, operated by staff of the Division of Coloproctology of the Department of Surgery and Anatomy of Ribeirão Preto Medical School at University of Sao Paulo.

METHOD

Medical records of 48 patients undergoing PRS from 2000 to 2011 were analyzed. Data evaluated included age at the time of surgery, gender of patients, clinical complaints, elapsed procedure time, type of anastomosis (manual suture or stapler), postoperative course (short and long-term), hospital stay length, recurrence or incontinence. All patients were followed up for 8 months or more. The surgical technique is shown in Figures 1 to 6.

RESULTS

Mean age of patients was 73.8 years (ranged from 49 to 101 years). Most of patients were women (85.4 versus 14.6% of men). Anal mass was reported in 44 patients (77.1%) and rectal bleeding in 22.8% (13 patients) – Figures 7 to 9.

The average surgical time was 72 minutes (range 40 to 90) – Figure 10. Mechanical anastomosis was performed in 72.9% cases and manual in 27.1% (Figure 11). Postoperative complications occurred in five cases – 10.5% (two cases of pneumonia and three cases of anastomotic leakages). There were no deaths related to the procedure, although one patient died a long time after surgery (myocardial infarction, about 2 months after surgery). The period of hospitalization ranged from 2 to 12 days, with an average of 3.91 days (Figure 12).

Out of the patients, 25%reported incontinence of stools. Continence was achieved in 2 cases (16.6%) among 12 (25%) patients with fecal incontinence.

Four patients presented recurrence of RP. They were submitted to a new Altemeier procedure, with successful outcomes.

DISCUSSION

The number of assessed patients leads to satisfactory evaluation of surgical results¹⁷.

The average age (73.8 years) was consistent with epidemiological data widely exposed on RP analysis, including even patients over 90 years – one of them was 101 years.

The largest number of women compared to the number of men is due to weakness of the perineal muscles associated with aging, notably in multiparous^3,4.

A brief procedure avoiding a laparotomy contributed to a shorter hospitalization (average of 3.91 days) and a low rate of postoperative complications, including infectious (complications rate of 10.5), without procedure-related mortality. It corroborates the feasibility of Altemeier procedure for elderly and high-risk patients.

The continence recovery involves no more stretch of the anal sphincter and pelvic floor fibers after surgery¹⁸. Only 16.6% (two patients) recovered continence after surgical procedure. The results may due to the long interval between symptoms onset and arrival at our hospital, with patients presenting irreversible neural and muscular damages of the pelvic floor on admission^4,5.

CONCLUSION

The PRS is a good surgical option for RP in elderly patients, with low morbidity and mortality, low recurrence rate and short hospitalization length.

Submitted on: 04/04/2012

Approved on: 05/11/2012

Study carried out at the Division of Coloproctology of the Department of Surgery and Anatomy of the Ribeirão Preto Medical School at Universidade de São Paulo (USP) – Ribeirão Preto (SP), Brazil.

Financing source: none.

Conflicts of interest: nothing to declare.

• 1. Jacobs LK, Lin YJ, Orkin BA. The best operation for rectal procidentia. Surg Clin North Am 1997;77(1): 49-70.
• 2. Ozgonul A, Uzunkoy, Sogut O, Yalcin M. Three-year experience with rectal procidentia patients. Med Res 2010;2(4):177-9.
• 3. Wassef R, Rothenberger DA, Goldberg SM. Rectal procidentia. Curr Probl Surg 1986;23(6):397-451.
• 4. Mann CV. Rectal procidentia. In: Morson BC, Heinemann W, editors. Diseases of the colon and rectum and anus. London: Medical Books; 1969. p. 238-50.
• 5. Gourgiotis S, Baratsis S. Rectal procidentia. Int J Colorectal Dis 2007;22(3): 231-43. Retraction in: Buhr HJ. Int J Colorectal Dis 2007;22(12):1561.
• 6. Hämäläinen KJ, Raivio P, Antila S, Palmu A, Mecklin JP. Biofeedback therapy in rectal procidentia patients. Dis Colon Rectum 1996;39(3):262-5.
• 7. Frykman HM, Goldberg SM. The surgical management of rectal procidentia. Surg Gynecol Obstet 1969;129(6):1225-30.
• 8. McKee RF, Lauder JC, Poon FW, Aitchison MA, Finlay IG. A prospective randomised study of abdominal rectopexy with and without sigmoidectomy in rectal procidentia. Surg Gynecol Obstet 1992;174(2):145-8.
• 9. Luukkonen P, Mikkonen U, Järvinen H. Abdominal rectopexy with sigmoidectomy vs. rectopexy alone for rectal procidentia: a prospective, randomised study. Int J Colorectal Dis 1992;7(4): 219-22.
• 10. Finlay IG, Aitchison M. Perineal excision of the rectum for procidentia in the elderly. Br J Surg 1991;78(6):687-9.
• 11. Williams JG, Rothenberger DA, Madoff RD, Goldberg SM. Treatment of rectal procidentia in the elderly by perineal rectosigmoidectomy. Dis Colon Rectum 1992;35(9):830-4.
• 12. Senapati A, Nicholls RJ, Thomson JP, Phillips RK. Results of Delorme's procedure for rectal procidentia. Dis Colon Rectum 1994;37(5):456-60.
• 13. Adair J, Gromsli MA, Nagle D. Single-incision laparoscopic sigmoidectomy and rectopexy case series. Am J Surg 2011;202(2):243-45.
• 14. Altemeier WA, Culbertson WR, Schwengerdt C, Hunt J. Nineteen years' experience with the one-stage perineal repair of rectal procidentia. Ann Surg 1971;173(6):993-1006.
• 15. Mikulicz J Zur operativen behandlung dis prolapsus recti et coli invaginati. Arch Klin Chir 1988;38:74-97.
• 16. Cirroco WC. The Altemeier procedure for rectal procidentia: an operation for all ages. Dis Rectum 2010;53(12):1618-23.
• 17. Fleming FJ, Kim MJ, Gunzler D, Messing S, Monson JR, Speranza JR. It's the procedure not the patient: operative approach is independently associated with an increased risk of complications after rectal procidentia repair. Colorectal Dis 2012;14(3):362-8. DOI: 10.1111/j.1463-1318.2011.02616.x.
• 18. Woods R, Voyvodic F, Schloithe AC, Sage MR, Wattchow DA. Anal sphincter tears in patients with rectal procidentia and faecal incontinece. Colorectal Dis 2003;5(6):544-8.

Publication Dates

• Publication in this collection
  08 Jan 2013
• Date of issue
  Sept 2012

History

• Received
  04 Apr 2012
• Accepted
  05 Nov 2012