Trip Answers

Question answered:13/06/08

We searched the NLH Gastroenterology and Liver Disease Specialist Library and the TRIP and Medline databases but found no guidance or studies to answer the question would abdominal surgery be effective in correcting a prolapsed colon in a patient who also has a colostomy.

 

All the literature we found relates to the surgical management of rectal prolapse that may be of relevance.

 

An e-Medicine article on notes in relation to surgical treatment:

 

“Surgical treatment can be divided into 2 categories according to the approach used to repair the rectal prolapse: abdominal procedures and perineal procedures. The choice of abdominal versus perineal procedure is mainly dictated by the patient's age and comorbidities.
In general, the abdominal procedures have a lower recurrence rate but a higher morbidity rate. The converse is true of perineal procedures. In general, treat older, debilitated patients (whose life expectancy is shorter) with a perineal procedure, and treat younger, healthier patients with abdominal procedures, although surgeons with large experience and low recurrence rates also advocate perineal procedures for their younger, healthier patients.
The choice of procedure is also dictated by the presence or absence of constipation. Children are treated with linear cauterization (not described in this article).
Surgical therapy for internal prolapse is usually avoided because results are poor, with relief of symptoms occurring in fewer than 50% of patients.” [1]

 

In addition, we located three studies that appear to concur with the information given in the e-Medicine article cited above.

 

Sobrado et al presented the findings of surgical treatment of rectal prolapse in 51 patients in 2004:

 

“The "best" surgical technique for the management of complete rectal prolapse remains unknown. Due to its low incidence, it is very difficult to achieve a representative number of cases, and there are no large prospective randomized trials to attest to the superiority of one operation over another. PURPOSE: Analyze the results of surgical treatment of complete rectal prolapse during 1980 and 2002. METHOD: Retrospective study. RESULTS: Fifty-one patients underwent surgical treatment during this period. The mean age was 56.7 years, with 39 females. Besides the prolapse itself, 33 patients complained of mucous discharge, 31 of fecal incontinence, 14 of constipation, 17 of rectal bleeding, and 3 of urinary incontinence. Abdominal operations were performed in 36 (71%) cases. Presacral rectopexy was the most common abdominal procedure (29 cases) followed by presacral rectopexy associated with sigmoidectomy (5 cases). The most common perineal procedure was perineal rectosigmoidectomy associated with levatorplasty (12 cases). Intraoperative bleeding from the presacral space developed in 2 cases, and a rectovaginal fistula occurred in another patient after a perineal rectosigmoidectomy. There were 2 recurrences after a mean follow-up of 49 months, which were treated by reoperation.

 

CONCLUSION: Abdominal and perineal procedures can be used to manage complete rectal prolapse with safety and good long-term results. Age, associated medical conditions, and symptoms of fecal incontinence or constipation are the main features that one should bear in mind in order to choose the best surgical approach.” [2]

 

Azimuddin et al. reviewed the medical records of patients undergoing surgery for rectal prolapse between the years 1989 to 1999. They found:

 

“A total of 36 perineal proctosigmoidectomies (PPSs) and 29 abdominal procedures [17 anterior resections (ARs) and 12 Ripstein procedures (RPs)] were performed during the 10-year period. Patients undergoing PPS were significantly older and had more comorbidities. Mean operating time and length of hospital stay were shorter for the PPS group. Early and late postoperative complication rates were also significantly lower in the PPS group. Six patients (16%) in the PPS group developed recurrence at a mean follow-up of 50 months. Operation under general anesthesia or removal of a longer segment of prolapsed bowel did not reduce recurrence after PPS. No full-thickness recurrence was noted after AR or RP. We conclude that abdominal procedures (AR and RP) have the lowest recurrence but at a significantly higher cost in terms of complications. PPS is a valuable option in selected patients and can be performed with minimal morbidity and a relatively low recurrence rate.” [3]

 

Finally, Boccasanta et al presented findings from a five-year retrospective study on surgery for complete rectal prolapse. The Medline abstract of this study reads:

 

“This retrospective study reports the results of our 5-year experience in the diagnosis and treatment of rectal prolapse with fecal incontinence by the abdominal (laparotomy or laparoscopy) and perineal approaches. Twenty-five patients (group A; 22 women and 3 men; mean age 57.3 years; range 22-76 years) were operated on by the abdominal approach and ten (group B; 8 women and 2 men; mean age 68.9 years; range 58-84 years) by the perineal approach. All patients were evaluated by clinical examination, proctosigmoidoscopy, pancolonic transit time, dynamic defecography, anorectal manometry, and anal electromyography preparatory to surgery.

 

In patients of group A, we performed an abdominal rectopexy in 19 cases (7 by laparoscopy) and in the remaining 6 cases, a sigmoid resection-rectopexy (3 of which were by laparoscopy). All patients of group B were treated by a perineal operation using Delorme's mucosectomy in 4 cases and Altemeier's rectosigmoidectomy with total perineoplasty in 6 cases. The mean follow-up was 38.8 months in group A and 25.7 months in group B. The postoperative complication rate was 8% (two cases) in group A, whereas no significant complications occurred in group B. Dyschezia and fecal incontinence improved significantly in both groups (P < 0.05 in group A and P < 0.005 in group B), whereas anoperineal pain was not significantly reduced. At 1-year follow-up, the recurrences rates were 8% in group A and 30% in group B. Rectopexy or resection-rectopexy proved to be a safe and effective procedure for external prolapse, without a discernible difference between the laparotomic and laparoscopic techniques. In selected cases, the perineal approach gives good results regarding fecal incontinence without complications, even if in these patients, the likelihood of recurrence is high.” [4]

 

References
1. Poritz L. Rectal prolapse. E-Medicine. August 2006. (http://www.emedicine.com/MED/topic3533.htm#section~Treatment)
2. Sobrado CW, Kiss DR and Nahas SC et al. Surgical treatment of rectal prolapse: experience and late results with 51 patients. Rev Hosp Clin Fac Med Sao Paulo. 2004 Aug;59(4):168-71. (http://www.hubmed.org/display.cgi?uids=15361980)
3. Azimuddin K, Khubchandani IT and Rosen L et al. Rectal prolapse: a search for the "best" operation. Am Surg. 2001 Jul;67(7):622-7. (http://www.hubmed.org/display.cgi?uids=11450773)
4. Boccasanta P, Rosati R and Venturi M et al. Surgical treatment of complete rectal prolapse: results of abdominal and perineal approaches. J Laparoendosc Adv Surg Tech A. 1999 Jun;9(3):235-8. (http://www.hubmed.org/display.cgi?uids=10414538)

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