Clinical outcomes of surgical management for recurrent rectal prolapse: a multicenter retrospective study

Rectal prolapse occurs when a mucosal or full-thickness layer of rectal tissue protrudes through the anal orifice. Problems with this condition include constipation, fecal incontinence, mucous discharge, and rectal bleeding [1]. Most rectal prolapse can be treated successfully with surgical procedures. While much data have been obtained on the treatment strategy for primary rectal prolapse, little is known about clinical outcomes of recurrent disease. Only 6 case series solely dealing with recurrent rectal prolapse have been published [2, 3, 4, 5, 6, 7]. All these studies were performed before 2006.

Surgical approaches for rectal prolapse can be divided into perineal and abdominal approaches. Traditionally, a perineal procedure such as Delorme or Altemeir operation was commonly used in elderly or frail patients while an abdominal procedure such as rectopexy with or without resection was reserved for younger and fitter patients [8, 9]. The frequency of laparoscopic abdominal repair of rectal prolapse has increased in recent years, with ventral mesh rectopexy being the most popular procedure [10, 11]. Two recent randomized clinical trials did not show any difference in morbidity, recurrence rate, or quality of life score between the abdominal procedure and the perineal procedure [12, 13]. Based on these data, this study investigated recent clinical outcomes of surgical management comparing perineal and abdominal approaches for recurrent rectal prolapse.

Unlike with primary rectal prolapse, there is no appropriate surgical guideline for recurrent rectal prolapse. There might be several reasons for the lack of surgical guidelines. First, few studies have investigated recurrent rectal prolapse. Second, various surgical methods have been performed for recurrent rectal prolapse. Third, only single-center studies with a limited number of patients have been conducted. The current study represents the largest one to date on surgical outcomes for recurrent rectal prolapse through multicenter research based on recent data.

When we divided the surgical approach into perineal and abdominal approaches, the perineal approach was found to be 1.68 times more frequently performed in patients with recurrent rectal prolapse. Although most abdominal approach surgeries were performed with laparoscopic surgery (96.5%), elderly and fragile patients were still receiving the perineal approach more often than the abdominal approach. This finding is in line with a systematic review by Hotouras et al. [9] showing that the traditional idea that older or high-risk patients should be offered the perineal approach cannot currently be challenged in the laparoscopic era. Among perineal approaches, Delorme with and without Thiersch procedures were the most commonly performed ones (82 patients, 85.4%). Among abdominal approaches, rectopexy was the most often performed one laparoscopically without bowel resection (51 patients, 89.5%). The Delorme procedure is simpler with less surgical risk than the Altemeir procedure because it only uses mucosal striping without rectal resection [19, 25]. Furthermore, to treat the associated lax anal sphincter, a Thiersch suture can be placed concomitantly with the Delorme procedure. Warwick et al. [26] reported that complications were not increased after placement of a Thiersch suture with the Delorme procedure and that recurrence rate could be potentially decreased with this combined technique. Likewise, laparoscopic rectopexy without bowel resection is simpler without having the risk of anastomotic leak compared with resection rectopexy. Considering these findings, in the clinic, less invasive surgical methods were applied to patients with recurrent rectal prolapse.

We found that the re-recurrence rate after surgery for recurrent rectal prolapse was 19.0% with a median follow-up duration of 40.0 months (range, 0.2–129.3 months). This finding was similar to other studies showing re-recurrence rate of 0% to 39.1% during a follow-up period of 9 to 60 months [2, 3, 4, 5, 15, 25, 27]. However, because these studies had small sample sizes, different surgical procedures, and various follow-up periods, care should be taken when comparing these rates. No study has investigated factors influencing re-recurrence after surgery for recurrent rectal prolapse yet. We analyzed causal factors that might influence re-recurrence after surgery for recurrent rectal prolapse. When confounding factors were controlled by logistic regression analysis, no factor was related to re-recurrence. Twenty-nine patients developed re-recurrence, with Kaplan-Meier curve estimates of 5.9%, 11.8%, and 16.3% after 1, 3, and 5 years, respectively. Because a short length of follow-up can lead to underestimation of the actual re-recurrence rate, further study with a longer term follow-up needs to be performed. Interestingly, the type of surgery (perineal or abdominal approach) for recurrent rectal prolapse did not affect the re-recurrence rate or the complication rate in this study. Until now, only 1 study has compared outcomes of perineal and abdominal approaches for recurrent rectal prolapse [4]. Although there was no significant difference in postoperative complications between the 2 approaches in a previous report, there were significantly more re-recurrences after surgery using a perineal approach (37.3%) compared with an abdominal approach (14.8%) for recurrent rectal prolapse [4]. However, the perineal approach was more frequently performed in older patients, which was not controlled with other confounding factors influencing the re-recurrence rate with a statistical method. Although no further study had compared perineal and abdominal approaches, some studies suggested that the type of surgery should be chosen according to the previous surgery for rectal prolapse. Fengler et al. [2] have suggested that repeat resectional procedures such as resection rectopexy following the Altemeir procedure or vice versa might result in complications attributable to ischemia in intervening segments between anastomoses. Hence, the authors recommended that a nonresectional surgery such as the Delorme procedure should be considered in recurrent rectal prolapse if a resectional procedure was previously performed. To avoid this problem, Pikarsky et al. [5] and Ding et al. [27] have recommended the Altemeir procedure for recurrent rectal prolapse because it can be successfully performed in patients who have previously received the Altemier procedure for rectal prolapse. The reason might be that the previous anastomotic line can be easily identified in the anal canal. Additionally, it is difficult to perform an abdominal approach because tissue planes are lost with little tissue to perform the rectopexy. Among 9 patients who underwent Altemeir as a previous surgery for rectal prolapse in this study, 1 patient following resection rectopexy and 2 patients following the Altemeir procedure for recurrent rectal prolapse had no postoperative complications or re-recurrence. Among the 5 patients who underwent resection rectopexy as a previous surgery for rectal prolapse in this study, only 1 patient received the abdominal approach (rectopexy without resection) and showed no complication or re-recurrence. With respect to other authors’ concerns, these findings indicated good results, although the number of cases was small. In this study, there was no significant difference in complication rate between the perineal and abdominal approaches. However, 4 reoperation cases due to complications occurred only when the perineal approach was used for recurrence after the Delorme procedure. Although Javed et al. [25] have suggested that repeated peritoneal approaches can be safe after failed Delorme procedures, their study only included 8 cases (Delorme, 3 cases and Altemeir, 5 cases). Our results indicate that repeated handling of the rectum through the anal canal, albeit via a nonresectional procedure, can jeopardize the viability of rectal tissue.

This study had some limitations. First, it was retrospective in nature. Second, the 2 patient groups, perineal and abdominal approach groups for recurrent rectal prolapse, were not completely comparable. Thus, further studies are required to validate our conclusions. Third, the operative approach was at the discretion of each institution or individual surgeon. Although a multicenter research was performed to produce universal results, selection bias might have affected our results. Such bias may explain why patients who underwent a perineal approach were older with higher ASA PS grades than those who underwent the abdominal approach for recurrent rectal prolapse. Lastly, we did not present changes in functional outcome after surgery for recurrent rectal prolapse. Because most institutes did not use a validated questionnaire for constipation or fecal incontinence, it was impossible to summarize those results.

For the recurrent rectal prolapse, the perineal approach is used for the old and fragile patients. The postoperative complications and re-recurrence rate between perineal and abdominal approach were not different significantly. No factor including surgical method affected re-recurrence for recurrent rectal prolapse.