Evidence - Rehn-Delorme transanal mucosal resection

  1. Literature summary

    The precise pathogenesis and etiology of rectal prolapse are still under discussion: Is it a sliding hernia, an intussusception, or a combination of both mechanisms? This clinical entity is characterized by the following functional anatomical pathologies which are present in varying degrees:

    • Atypically low Douglas pouch (3, 13, 19)
    • Levator ani muscle diastasis
    • Functional weakness of the internal and external anal sphincters (3, 13)
    • Weak pelvic floor muscles
    • Pudendal neuropathy (13, 19)
    • Mobile mesorectum with inadequate posterior and lateral fixation of the rectum (13, 19, 29)
    • Elongated, redundant sigmoid colon (13,19,29)

    Ultimately, it remains unclear which of the changes are conducive to rectal prolapse and which are sequelae, and this is almost impossible to clarify in diagnostic work-up.

    Treatment aims to eliminate the prolapse and restore defecation and continence. The following treatment options are available (13, 19, 29):

    • Fixation of the rectum to the sacrum
    • Resection or plication of the redundant bowel

    A distinction is made between transabdominal and local procedures.

    1. Transabdominal procedures (laparotomy, laparoscopy)

    1.1 Rectopexy

    The rectum is fixed to the presacral fascia, thus eliminating its inadequate fixation to the sacrum. Stretching of the rectum relieves the pressure on the pelvic floor and is intended as a means of regenerating the pelvic floor muscles. Rectopexy includes the following types of procedure:

    1.1.1 Suture rectopexy
    In suture rectopexy first performed by Sudeck (24), the rectum is mobilized down to the pelvic floor and attached to the promontory with interrupted sutures. It is hypothesized that mobilization-induced presacral fibrosis will further strengthen the fixation. Recurrence rates of up to 10% have been reported and the range of postoperative functional disorders described varies widely (16).

    1.1.2 Rectopexy with foreign material
    Foreign material supposedly contributes to a more extensive presacral fixation of the mobilized and stretched rectum. Ripstein procedure (anterior sling rectopexy (22)), Orr-Loygue procedure (lateral fixation) and Wells procedure (posterior mesh rectopexy (26)) differ in their position of the material. Another variant is anterior rectopexy, where the rectum is mobilized only in the rectouterine pouch and attached to the promontory with a mesh fixed anteriorly to the rectum (6). This technique is based on the concept that mobilization of the rectum results in postoperative defecation difficulties (18, 23).

    The above procedures have recurrence rates of up to 12%, and after the Wells procedure almost all patients have a tendency of constipation. The type of foreign material does not affect the recurrence rate (5, 20, 28); Marlex excels in terms of the lowest infection rates (12, 14). However, the use of foreign material has its own risks: Fistulas, stenoses and erosions (10). Studies suggest that problems with continence and constipation are more likely to be resolved with simple suture rectopexy rather than with foreign material (8).

    1.1.3 Resection rectopexy (Frykman-Goldberg)
    The procedure described by Frykman (9) combines rectopexy and sigmoidectomy, thereby aiming to achieve the following:

    • Removal of the redundant sigmoid which exerts caudal pressure or can become angulated against the rectum causing obstruction
    • Enhanced fixation of the stretched rectum
    • Rectal fixation following fibrous scarring around the descendorectostomy
    • Improvement of preexisting constipation

    The combined procedure has a low risk of recurrence, improves continence comparable to that of rectopexy without resection, but markedly lowers the potential risk of postoperative constipation apparently due to the resection (15).

    Surgical aspects of abdominal procedures
    The access route—open or laparoscopic—does not impact the recurrence rate or functional results (4, 12). The benefits of minimally invasive surgery (MIS) include reduced postoperative pain, faster convalescence and shorter hospital stays.

    While incomplete division of the lateral stalks during rectal mobilization appears to increase the recurrence rate, the functional results are more favorable (16, 18, 23).

    2. Local procedures (perineal, transanal)

    The original benefit of local procedures was that they avoided laparotomy; in view of the MIS techniques available today, this aspect has lost its significance. While wrapping the anus with subcutaneous foreign material or muscle has become obsolete due to marked complication and recurrence rates, the following local measures may be considered in patients with contraindications for invasive procedures (21):

    2.1 Rehn-Delorme procedure
    In the procedure described by Rehn (7) and modified by Delorme, the mucosa is separated transanally from the sphincter and muscularis propria and the denuded muscularis layer is plicated longitudinally around the prolapsed rectum; this shortens the muscularis tube. After resection of the redundant mucosa, it is reapproximated. The procedure may be performed under analgesic sedation but is not suitable in pronounced prolapse. While studies demonstrate improved continence, the recurrence rate is rather high.

    2.2 Perineal rectosigmoidectomy (Altemeier)
    In the Altemeier procedure (1), transanal resection of the rectum and parts of the sigmoid, with subsequent restoration of bowel continuity, is carried out at the level of the dentate line as when fashioning a colon pouch (30).  This can be combined with levatorplasty (27). While the recurrence rate is lower compared to the Rehn-Delorme procedure, the functional results regarding incontinence and fecal smearing are less favorable.

    Selection of the procedure

    Due to the present inconsistent data, no evidence-based recommendations can be issued for the choice of procedure used to manage rectal prolapse (2). There is no clearly superior technique in the management of rectal prolapse, with each having its own risks and benefits:

    • Transabdominal procedures are characterized by a lower recurrence rate 
    • The effectiveness of sole suture rectopexy is comparable to that of pexy procedures with foreign material
    • The use of foreign material has its own risks
    • Resection rectopexy appears to have benefits in cases of preexisting constipation, in particular in elongated sigmoid colon
    • Laparoscopy has no drawbacks and offers the benefit of less postoperative pain and quicker convalescence
    • While local procedures cause less surgical stress, the functional results are poorer 

    The key criteria for the choice of procedure are patient resilience, size of the prolapse and reported functional disorders.

    Abdominal access not possible (multimorbid high risk patient)
    > Minor prolapse: Rehn-Delorme
    > Major prolapse: Altemeier
    > Incontinence: additionally, levatorplasty

    Abdominal access possible: Rectopexy, preferably laparoscopic
    > Suture rectopexy
    > Mesh rectopexy
    > Preexisting incontinence: no resection
    > Preexisting constipation with redundant sigmoid: Resection

  2. Ongoing trials on this topic

  3. References on this topic

    1. Altemeier WA, Giuseffi J, Hoxworth P (1952) Treatment of extensive prolapse of the rectum in aged or debilitated patients. AMA Arch Surg 65: 72–80

    2. Bachoo P, Brazzelli M, Grant A (2001) Surgery for complete rectal prolapse in adults (Cochrane Review). Cochran Libary, Issue 2

    3. Broden B, Snellman B (1968) Procidentia of the rectum studied with cineradiography. A contribution to the discussion of causative mechanism. Dis Colon Rectum 11: 330–347

    4. Bruch HP, Herold A, Schiedeck T, Schwandner O (1999) Laparoscopic surgery for rectal prolapse and outlet obstruction. Dis Colon Rectum 42: 1189–1194; discussion 1194–1195

    5. Corman ML (1988) Rectal prolapse. Surgical techniques. Surg Clin North Am 68: 1255–1265

    6. D’Hoore A, Cadoni R, Penninckx F (2004) Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg 91: 1500–1505

    7. Delomre R (1900) Surle traitment des prolapses du rectum totaux pour lèxcision de la muscueuse rectale ou rectocolique. Bull Mem Soc Chir Paris 266: 499–518

    8. Duthie GS, Bartolo DC (1992) Abdominal rectopexy for rectal prolapse: a comparison of techniques. Br J Surg 79: 107–113

    9. Frykman HM (1955) Abdominal proctopexy and primary sigmoid resection for rectal procidentia. Am J Surg 90: 780–789

    10. Holmstrom B, Broden G, Dolk A (1986) Results of the Ripstein operation in the treatment of rectal prolapse and internal rectal procidentia. Dis Colon Rectum 29: 845–848

    11. Jarrett ME, Matzel KE, Stosser M et al. (2005) Sacral nerve stimulation for fecal incontinence following surgery for rectal prolapse repair: a multicenter study. Dis Colon Rectum 48: 1243–1248

    12. Kariv Y, Delaney CP, Casillas S et al. (2006) Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study. Surg Endosc 20: 35–42

    13. Kuijpers HC (1992) Treatment of complete rectal prolapse: to narrow, to wrap, to suspend, to fix, to encircle, to plicate or to resect? World J Surg 16: 826–830

    14. Kuijpers JH, Morree H de (1988) Toward a selection of the most appropriate procedure in the treatment of complete rectal prolapse. Dis Colon Rectum 31: 355–357

    15. Luukkonen P, Mikkonen U, Jarvinen H (1992) Abdominal rectopexy with sigmoidectomy vs. rectopexy alone for rectal prolapse: a prospective, randomized study. Int J Colorectal Dis 7: 219–222

    16. Madiba TE, Baig MK, Wexner SD (2005) Surgical management of rectal prolapse. Arch Surg 140: 63–73

    17. Marchal F, Bresler L, Ayav A et al. (2005) Long-term results of Delorme’s procedure and Orr-Loygue rectopexy to treat complete rectal prolapse. Dis Colon Rectum 48: 1785–1790

    18. Mollen RM, Kuijpers JH, Hoek F van (2000) Effects of rectal mobilization and lateral ligaments division on colonic and anorectal function. Dis Colon Rectum 43: 1283–1287

    19. Nicholls RJ (1994) Rectal prolapse and the solitary ulcer syndrome. Ann Ital Chir 65: 157–162

    20. Novell JR, Osborne MJ, Winslet MC, Lewis AA (1994) Prospective randomized trial of Ivalon sponge versus sutured rectopexy for full-thickness rectal prolapse. Br J Surg 81: 904–906

    21. Oliver GC, Vachon D, Eisenstat TE et al. (1994) Delorme’s procedure for complete rectal prolapse in severely debilitated patients. An analysis of 41 cases. Dis Colon Rectum 37: 461–467

    22. Ripstein CB (1952) Treatment of massive rectal prolapse. Am J Surg 83: 68–71

    23. Speakman CT, Madden MV, Nicholls RJ, Kamm MA (1991) Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study. Br J Surg 78: 1431–1433

    24. Sudeck P (1922) Rektumprolapsoperation durch Auslösung des Rektum aus der Excavatio sacralis. Zentralbl Chir 20: 698–699

    25. Watts AM, Thompson MR (2000) Evaluation of Delorme’s procedure as a treatment for full-thickness rectal prolapse. Br J Surg 87: 218–222

    26. Wells C (1959) New operation for rectal prolapse. Proc R Soc Med 52: 602–603

    27. Williams JG, Rothenberger DA, Madoff RD, Goldberg SM (1992) Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy. Dis Colon Rectum 35: 830–834

    28. Winde G, Reers B, Nottberg H et al. (1993) Clinical and functional results of abdominal rectopexy with absorbable mesh-graft for treatment of complete rectal prolapse. Eur J Surg 159: 301–305

    29. Yakut M, Kaymakcioglu N, Simsek A et al. (1998) Surgical treatment of rectal prolapse. A retrospective analysis of 94 cases. Int Surg 83: 53–55

    30. Yoshioka K, Ogunbiyi OA, Keighley MR (1998) Pouch perineal rectosigmoidectomy gives better functional results than conventional rectosigmoidectomy in elderly patients with rectal prolapse. Br J Surg 85: 1525–1526


Bhattacharya P, Hussain MI, Zaman S, Randle S, Tanveer Y, Faiz N, Sarma DR, Peravali R. Delorme's v

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