Perineal Options

M Thompson, Consultant Colorectal Surgeon, Portsmouth

Powerpoint File

The perineal procedures [1-15] for correction of a rectal prolapse remain popular, because many patients are frail and elderly, and are assumed to be less able to withstand abdominal procedures. The functional results are acceptable, and avoid one of the common adverse effects of the original abdominal approaches, namely constipation [16].

The two common perineal approaches are the Delorme's [1-8] and the Altemeier procedures. [9-15] In the United Kingdom the Delorme's procedures is the most popular technique, the Altemeier being more popular in The States.

The Delorme's procedure was first described by the French Military Surgeon, Edmond Delorme in 1901, and although the operation was initially seen to be technically simple and safe, it fell into disfavour after anecdotal reports of high recurrence rates and high postoperative morbidity and mortality.

In the past twenty years its popularity has re-emerged [1-8], but high recurrence rates continue to be reported [8]. Anorectal physiology studies [17] show that Delorme's results in a decrease in rectal compliance with virtually no change in sphincter pressure, which results functionally in an improvement in constipation and continence. Only a small percentage of patients have a decrease in continence

Altemeier's procedure [9] is a trans-perineal/anal resection of the prolapsed bowel with a sutured coloanal or low colorectal anastomosis performed through the anal canal.

Its advocates in the USA claim lower recurrence rates, but this is not universal [11,15]. The current ACPGBI randomised-controlled Trial comparing abdominal and perineal treatment of rectal prolapse may provide some reliable evidence on which is the better operation.

The rate of recurrent prolapse for all operations should be determined from Kaplan Meier curves, and expressed as the predicted period free of recurrence over a fixed length of time in surviving patients.

Following Delorme's procedure recurrence continues at a fixed rate with no evidence that this plateaus. This may be true for all operations for prolapse, the difference between techniques being simply the rate at which recurrence occurs. The implication of this data is that eventually all patients will recur if they live long enough!

References.

1. Tobin SA, Scott IHK. Delorme operation for rectal prolapse. Br J Surg 1994; 81: 1681-4

2. Lechaux JP, Lechaux D, Perez M. Results of Delorme's procedure for rectal prolapse: Advantages of a modified technique. Dis Colon Rectum 1995; 38: 301-7

3. Uhlig BE, Sullivan ES. The modified Delorme operation: its place in the surgical treatment for massive rectal prolapse. Dis Colon Rectum 1979; 22: 513-21

4. Monson JRT, Jones NAG, Vowden P, Brennan TG. Delorme's operation: the first choice in complete rectal prolapse? Ann R Coll Surg Engl 1986; 68: 143-6

5. Graf W, Ejerblad S, Krog M, Pahlman L, Gerdin B. Delorme's operation for rectal prolapse in elderly or unfit patients. Eur J Surg 1992; 158: 555-7

6. Christiansen J, Kirkegaard P. Delorme's operation for complete rectal prolapse. Br J Surg 1981; 68: 537-8

7. Johnson E, Nygaard K, Bakka A. Rectal prolapse. Experiences with rectopexy and Delorme's operation. Tidsskr Nor Laegeforen 1993; 113: 2693-5

8. Watts AMI, Thompson MR. Evaluation of Delorme's procedure as a treatment for full-thickness rectal prolapse. Br J Surg 2000; 87: 218-22

9. Altemeier WA, Culbertson WR, Schowengerdt C, Hunt J. Nineteen Years' Experience with the On-Stage Perineal Repair of Rectal Prolapse. Ann Surg 1971; 173 (6): 993-1001

10. Ramanujam PS, Vankatesh KS, Fietz MJ. Perineal excision of rectal procidentia in elderly high-risk patients: a ten-year experience. Dis Colon Rectum. 1994; 37: 1027-30

11. Friedman R, Muggia-Sulam M. Freund HR. Experience with the one-stage perineal repair of rectal prolapse. Dis Colon Rectum 1983; 26 (12): 789-91

12. Williams JG, Rothenberger DA, Madoff RD, Goldberg SM. Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy. Dis Colon Rectum. 1992; 35: 830-4

13. Johansen OB, Wexner SD, Daniel N et al. Perineal rectosigmoidectomy in the elderly. Dis Colon Rectum 1993; 36: 767-72

14. Kimmins MH, Evetts BK, Isler J, Billingham R. The Altemeier repair; outpatient treatment of rectal prolapse. Dis Colon Rectum 2001; 44 (4): 565-70

15. Paltved CV, Burcharth F, Beck H, Bruun E, Christiansen J. Treatment of total rectal prolapse by perineal rectosigmoidecty - Altermeier's procedure. Adv Clin Exp Med 2003; 12(4): 537-41

16. Mann CV, Hoffman C. Complete rectal prolapse: the anatomical and functional results of the treatment by an extended abdominal rectopexy. Br J Surg 1988; 75: 34-7

17. Plusa SM, Charig JA, Balaji V, Watts, Thompson MR. Physiological changes after Delorme's procedure for full-thickness rectal prolapse. Br J Surg 1995; 82: 1475-8