Se Surgical Management of Rectal Prolapse Thandinkosi E. Madiba, MMed(Chir), FCS(SA); Mirza K. Baig, FRCS; Steven D. Wexner, MD, FACS, FRCS, FRCS (Edin) Background: The problem of complete rectal prolapse fs formidable, with no clear predominant treatment of choice. Surgical management is aimed at restoring physi- ology by correcting the prolapse and improving conti- rence and constipation with acceptable mortality and re- ceurrence rates. Abdominal procedures are ideal for young, fic patients, whereas perineal procedures are reserved for older frail patients with significant comorbidity. Laparo- scopie procedures with their advantages of early recov ey, less pain, and possibly lower morbidity are recently added options. Regardless ofthe therapy chosen, match- ing the surgical selection to the patient is essential. Objective: To review the present status of the surgical Uweatment of rectal prolapse. Data Sources: Literature review using MEDLINE, All articles reporting on rectopexy were included Study Selection: Anicles reporting on prospective and retrospective comparisons were included. Case reports were excluded, as were studies comparing data with his- torical controls, Data Extraction: The results were tabulated to show outcomes of different studies and were compared. Stud- {es that did not report some of the outcomes were noted as “not stated.” Data Synthesis: Abdominal operations offer not only lower recurrence but also greater chance for functional improvements. Suture and mesh reclopexy produce equivalent results. However, the polyvinyl alcohol (Iva- lon) sponge rectopexy is associated with an increased risk. of infectious complications and has largely been absan- doned. The advantage of adding a resection to the rec- topexy seems to be related to less constipation. Laparo- scopic rectopexy has similar results to open rectopexy buthasall ofthe advantages related to laparoscopy. Perineal procedures are better suited to frail elderly patients with extensive comorbidity Conelusions: Abdominal procedures are generally bet- ter for young fit patients; the results ofall abdominal pro- cedures are comparable. Suture and mesh rectopexy are siill popular with many surgeons—the choice depends on, the surgeon's experience and preference Similarly, the pro- cedure may be done throuigh a laparoscope or by laparo- tomy. Perineal procedures are preferable for patients who are not fit for abdominal procedures, such as elderly Frail patients with significant comorbidities, The decision be- tween perineal rectosigmoidectomy and Delorme proce- dures will depend on the surgeon's preference, although the perineal rectosigmoidectomy has better outcomes, Arch Surg. 2005;140:63-73, ECTAL PROLAPSE, OR PROC- dlentia, is defined as a pro- trusion of the rectum be yond the anus Complete or dal nerve neuropathy,** and (4) the lack fof normal fixation of the rectum, with a ‘mobile mesorectuin and lax lateral ligs- ‘ments.*” With this abnormality, the small Affiliations: Department of Surgery University of KwaZulu-Natal, Durban, South Aftica (Dr Madiba); and Colorectal Unit (De Mada), Department of Colorectal surgery (Drs Baig and Wexner), Cleveland Clinic Florida, Weston, full-thickness rectal pro- lapse is the protrusion of all of the rectal wall tnrough the anal canal; ifthe rectal wall has prolapsed but does not protrude through the anus, itis called an occult (in- ternal) rectal prolapse ora rectal intussus- ception? Full-thickness rectal prolapse should be distinguished from mucosal pro- lapse in which there is protrusion of only the rectal or anal mucosa." Prerequisites for the development of rectal prolapse are (1) the presence of an abnormally deep pouch of Douglas,** (2) the lax and atonic condition of the muscles of the pelvic floor and anal canal,*? (3) weakness of both internal and external sphincters, often with evidence of puden- intestine, which lies against the anterior wall of the rectum, may force the rectum ‘out through the anal canal.” Rectal prolapse occurs at the extremes of age."* In the pediatric population, the condition is usually diagnosed by the age of 3 years, with an equal sex distribution. In the adult population, the peak inc- dence is alter the fith decade and women are more commonly affected, represent- {ng 80% to 90% of patients with rectal pro- lapse." Patients with complete rectal pro- lapse have markedly impaired rectal adaptation to distention, which may con- tribute to anal incontinence, and conse- quently more than half ofthe patients with rectal prolapse have coexisting incont (©2003 American Medical Association. AI rights reserved, Downloaded From: http:/jamanetwork.com/ on 10/25/2016Table 1. Results of Suture Rectopexy for Rectal Prolapse Source M_Design ‘Mortal, 9 constipation, = Recurrence, Wa. (3) _ Falow-ap, mea carte 1988 2 Ns o ns 18) 1 Novell etal 1904 32 Prospective 0 1504) 314) 18) a Gat tl 1096 53 Ratospeave © BE} -DEH)Z7E 5) or Kanna ata 1996 65 Prospective 0 75(+) BK) 0 6 ri at 1007 2 NS 0 ars) is 0 a ‘Laparoscopic Kallokumpu tal 2000 17 Prospective o 2+) 70 (+) 20) 2 Heah et l2000 25 Prospective 0 504) we) Ns % esl etai" 1090 22 Prospective 0 is ns 26) a Bruchetal 1909 32 Prasecte 0 4) 16 (4) 0 2” Benoistatl22001 18 Ratospecive © ma) ne Ns is Abbreviations: WS, ot tated (improve), worsening rence.” Constipation is associated with prolapse in 15% to 65% of patients." straining may force the ante- ror wall of the upper rectum into the anal canal, perhaps causing a solitary rectal ulcer due to mucosal trauma." The aim of treatment is to control the prolapse, re- store continence, and prevent constipation or impaired evacuation.” This goal can be achieved by (1) resection or plication of the redundant bowel and/or (2) fixation of the rectum to the sacrum." A strong and functional pel- vie floor may be restored by plicating the puborectalisan- terior to the rectum.’ The rationale for rectal fixation is to keep the rectum attached in the desired elevated position until st becomes fixed by sear tissue. In incontinent pa- tients, the patulous sphincter ani begins to regain its tone approximately 1 month after the procedure, and fall con- Uinence is generally restored within 2 to 3 months.” Nu- merous procedures have been described for the treat- ‘ment of rectal prolapse and are generally eategorized into perineal or abdominal approaches, ABDOMINAL PROCEDURES Many abdominal techniques have been described, dif fering only in the extent of rectal mobilization, the meth- ods used for rectal fixation, and the inclusion of exclu- sion of resection? Suture Rectopexy This operation, frst described by Cutait in 1959,” involves thorough mobilization and upward fixation of the rectum. The mobilization and subsequent healing by fibrosis tends okeep the rectum fixed inan elevated positionasadhestons form, attaching the rectum tothe presacral fascia." Table 1 lisisseries with more than 10 patients undergoing suture rec- topexy. Therewasno reported mortality, and recurrence rates ranged from 0% to 27%.!"2""* With the exception of onese- res with a recurrence rate of 27%,” the majority of reports claimed rates ranging from 0% to 3%, with most ofthe re- ports showingan improvement in fecal continence. Theit- fluence on constipation was variable, wit different studies showing improvement, deterioration, or no effect on con- stipation. Briel etal!" ina review of suture reetopexy in 24 patients with rectal prolapse and incontinence noted abel- ter overall clinical outcome in males. They postulated that the low success rate in female patients might be explained by the presence of an occult sphincter defect. This assump- tion was underlined by history of obstetric tear orepisiotomy ‘nfemale patients with persistent ana incontinence alter rec- topexy. These patients should be considered as candidates {or endosnal ultrasound and subsequent sphincter repair. Prosthetic or Mesh Rectopexy Insertion of a foreign material during rectopexy is com- monly performed with the assumption that this mate- rial evokes more fibrous issue formation than ordinary suture rectopeay.” Materials used include fascia lata; non- absorbable synthetic meshes such as nylon, polypropy- lene (Prolene [Ethicon Ine, Somerville, NJ], Marlex [CR Bard, Murray Hill, NJ}), polyvinyl alcohol (Ivalon; Dow ‘Corning, Midland, Mich), and polytef (Teflon; CR Bard); and absorbable meshes stich as polyglactin (Vicryl; Ethi- con Inc) and polyglycolic acid (Dexon; Davis Geck, Dan- bury, Conn). There are 2 types of mesh rectopexy: pos- terior mesh rectopexy and anterior sling rectopexy (Ripstein procedure). Posterior Mesh Rectopexy. Alter rectal mobilization, a prosthetic material or mesh is inserted between the sacrum and the rectum, sutured into the rectum, and then su- tured into the periosteum of the sseral promontory. Al- ‘though fascia lata was used in the early deseription of the procedure in general, itis no longer used. Table 2 lists series in which posterior mesh rectopexy was used with ‘more than 10 patients. Four series used polyvinyl alco- hol sponge rectopexy and the rest used other meshes. The sponge rectopexy, first described by Wells in 1950," in- volves insertion of the polyvinyl alcohol sponge pros- thesis in front of the sacrum, between the sacrum and the rectum. Mortality rates ranged from 0% 0 3%" land recurrence rales were reported at 3%." provement in continence occurred in 3% to 40%, but there ‘was a mixed response of constipation to this type of re topeay.!9!5222120" Although the sponge rectopexy was popular before 1980, it has lost popularity and is con- fined to studies before 1004. Other nonabsorbable syn- thetic meshes have replaced the sponge, and more re- im. (©2003 American Medical Association. AI rights reserved, Downloaded From: http:/jamanetwork.com/ on 10/25/2016Table 2, Results of Posterior Mosh Rectopexy for Rectal Prolapse Toray, sous N___besign__esir__o.(3)__Contnene,%»_Constpation, ‘Open Panel andHavley*1972 101 Revorpacvw = 1 214) ns 39) 8 Morgan et 21972 150 Revospecie «= 14) 2) 58+) 49) 36 Mann and Hotman.” 1988 50S 1 0 BUH) an Ns is Noval tal 1004 31 Prospective 1 0 3(4) a0 20) a Scag ot a 1904 16 Revospecive = 20 194) WO) 0 2 Notas 1973 | wo NS 6 Ns Ns hs ° rm Nighy and Shower 1984 100 NS 2 0 ey Ns 0 Py Sajan etal 1960, 16 Prospective 2 0 754) wore ns is 6 Laukkonan at a 192 15 Prospective 40 2314) 100 ° is Wnde etl 1008 7 Prospective «3440 7) ns 0 51 Galland abou" 1007 «37 Prespactws «342 a Ns 1@) u Yt tal? 1908 4 Revospecive «= 20 a Nc 0 2 oat" 1900 95 Revospecive = 211) 2514) 24(+) 66) 3 olen etal 2000, 18 Prospective 5 NS Ns Ne o 2 Taparszopie Himpens el 1000 37 Prospective 2 0 24) ay ° 2% Darel 1005 2 Prospective 2 0 Ns NS ° e oceania eta! 1000 10_—~Progpactv 2 0 w o 0 » “tl etal 2000, 20° Prospective 2 0 76(4) No 18) 2 Benoit al 2001 18 Revospecive = 20 10(4) 20 Ns is Abbrvations: NC, n change: MS, ot tated (+), proven (2), worsening “1 ndats poy aleool spnge (lon): 2, olpropvan Paine [tion (wiry tan ine: 4 olay ned (Osx: Dave & ack, Danbury Cnn) 5, poe Teton: Bad); Mera cently absorbable meshes have been introduced. A number of authors" have shown thatthe use of both absorb- able and nonabsorbable meshes achieved similar re- sults. The mortality rate was O% to 1% and the recur rence rates were 0% to 6% for both absorbable" and nonabsorbable’?! meshes, There was an over- all improvement in continence, with conflicting results in terms of constipation (Table 2). A number of studies have evaluated the efficacy of ab- sorbable mesh in posterior mesh rectopexy. Winde etal” assessed 47 patients with rectal prolapse in whom they com- pared 2 types of absorbable meshes (polyglycolic acid and polyglactin) and noted mortality and recurrence rates imi- lar to those with other nonabsorbable meshes. Galil and aba” compared polyglycolic acid and polypropylene in the treatment of rectal prolapse in 37 consecutive patients and produced similar results with both types of meshes. These results have been reproduced by others." The mortality and recurrence rates are similar to figures re- ported alter placement of nonabsorbable meshes, Significant pelvic sepsis is a major contributor to post- ‘operative morbidly, having been reported in 2% to 16% of patients with prosthetic rectopexy.1?2!59*-" Poly. vinyl alcohol sponge placement carries an increased risk of infectious complications." In 1996, Athanasiadis et al! performed posterior mesh rectopexy in 222 pa- nts, with sigmoidectomy in 145. They used polyvinyl alcohol in 87 patients, polyglactin in 109, and polytef in 26. The infection rate associated with polytel mesh was (0% and that associated with absorbable material with- ut resection was 0%, whereas the presence of resection Increased the mortality rate to 1%. In patients with poly- vinylalcohol sponge rectopexy, the infection rate was 3% Ine, Soman, Ml Marie (CR Bard, Mura Hl Ml) 3,pygactin Etheoa ne) without resection and increased to 3.79% in the presence of resection. Insertion ofa mesh during rectopexy with- ut resection appears to be reasonable, as it was associ- ated with 0% of very low mortality 94559 ‘Because the main predisposing factor for infection of the {implant isan infected pelvic hematoma, drainage of the pi sacral pelvic region during surgery is recommended." The converse argument is that a pelvic drain may serve as source of infection. Ithis complication does occur, how- ever, removal of the foreign material isadvisable, as sepsis does not resolve until all foreign material is re- moved °°" In general, other materials are preferred lover the polyvinyl alcohol sponge as this material is highly prone to infection." Furthermore, inthe presence of an Anastomosis in patients having a synchronous resection, the theoretical risk of infection is increased *" Ripstein Procedure (Anterior Sling Rectopexy). This op- ction was fist described by Ripstein in 1952." Al plete mobilization ofthe rectum, an anterior sing of fs- ia at orsynthetic material is placed in front ofthe retain fd sutured to the scral promontory. The rationale is to restore the posterior curve ofthe rectum to minimize the cllcet of increased intra-abdominal pressure. The oper: tion provides firm anterior lascal support in patients with atrophic pelvic strictures and restores the normal ana- tome position of the rectum, Fable 3 listsseries with more than 10 patints undergoing the Ripstein procedure. Mor- tality rates ranged betieen O% and 2.8% and recurrence rates between OW and 13%, and there was a tend tovward {improvement in continence and a mixed response to con- stipation."""°25" although the Ripstein procedure thas been denigrated on the grounds that it causes ob- (©2003 American Medical Association. AI rights reserved, Downloaded From: http:/jamanetwork.com/ on 10/25/2016Table 3. Resulls of the Ripstein Procedure for Rectal Prolapse ‘wor, Tecuvonce, Followup, s ‘ Design No%e" Continence, % Constipation, %= Ha. (4), mo ‘une etalT082 B_Ratospecie 0 a) we) 6112) et 10) Holmstdm atl 1986 108 NS 308) ary) 7 40) 82 Roberts etal 1988135 Ratospctve 1 (06) 784) (4) 13(19 a Winde etal 1008, 47 Prospective = 2) 7) 0 51 Tara at.” 1008 182 Ratospecve © 1(07) 184) 100) 50 Scag ot a 1904 16 Retospecive 24) ° 2 Shut tl 1096 2h Prospacve ey) us ns Shu ot 2000 Can) a 214) 12) 2 10) Abbrvations: NC, na change: MS, ot tated (+), mproverent (3), worsening Table 4, Results of Suture Rectopexy With Resection ecarenee, Follow-up, s 1 dasign Wo. (%)__continence, Constipation, 2e a. me Ope Frykman and Goldberg" 1969 8. ~Rerospecive NS us ns 0 Watt al 1085 1h fatospecive 0 78(+) us 20) Saja etal 1960, 18 Prospects (4) 20(4) Ns Luann ta 192 15 Prospects 1067) BU) 6014) 0 Tiana tal” 1008 18 Rospecive 0 114) 564) is 10 Prospectve 0 0 ns 0 2 Prospects ac) 18) 0 19° Retrospecive 0 w o. 0 Kiet 1000 176 __Ratvospecive MS 50) a) 946) ‘apareopie Stanton ot a 1908 3 Prospects 70(+) a) 0 8 Xymos tal 1900 10 Prospects = 100(+) ua is 2 Benoit tl 2001 16 Retospecive 0 100(+), ° Ns ns ‘Abbrviton: NA ot apple NS, not ae (=), improvement structed defecation," series looking al constipation af- Resection ter the Ripstein procedure have yielded contlicting re- sults (Table 3). Moreover, to limit the incidence of obstruction, Ripstein himself, with MeMahan, modified the procedure to include posterior fixation of the mesh to the sacrum.” In this situation, the lateral mesh is anteri- orly sutured to the rectum, with a gap deliberately let be- ‘oven the ends to obviate narrowing. Intraoperative rigid proctoscopy can help determine the snugness of the wrap and caliber of the rectal lumen. Male patients exhibit a higher incidence of recurrent prolapse because of techni- cal difficulties with a narrow pelvis." In 1088, Roberts eta” reviewed their experience with the Ripstein procedure in 135 patients during a 22-year period at the Lahey Clinic, Burlington, Mass; they noted 252% complication rate, the most serious complication being presacral hematoma, which occurred in 8% of cases. The overall recurrence rate was 10%. However, the re- currence rate in men was 3 times that in women (24% vs 89, respectively). They postulated that the reason for a high failure rate in men might be difficulty in mobiliz- {ng the rectum in the narrow male pelvis. Technical di- ficulties atthe time of the original operation were impli- cated in 50% of eases of male patients with recurrence.” The concept of rectosigmoid resection is based on the ob- servation that afier low anterior resection, a dense area of fibrosis forms between the anastomoticsulure lineand the scrum, securing the rectum to the sacrum, Other advan- tages include (1) resection of the abundant rectosigmoid, whichavoids torsion or volvulus; (2) achieving astraighter course ofthe left colon and litle mobility from the phreno- colic ligament downward, which acts as yet another fixa- tivedevice'**";and (3) relief of constipation ina selected ‘group of patients.’ ILis well suited to patients with along, redundant sigmoidandalonghistory ofconstipation.* How ever, sigmoid resection alone for rectal prolapse has not been poplar and is confined to studies before 1980. The addition of sigmoid resection to rectopexy (re tion rectopexy; Prykman-Goldberg procedur bines the advantages of mobilization of the rectum, sig- ‘oid resection, and fixation of the rectum. Most of the series describe resection reclopexy in which resection is combined with suture rectopexy. Few studies have ad- dressed a combination of resection and posterior mesh rec- topexy. Fable 4 lists series with more than 10 patients undergoing resection rectopexy (suture rectopexy and re- (©2003 American Medical Association. AI rights reserved, Downloaded From: http:/jamanetwork.com/ on 10/25/2016section). The mortality rates ranged from 0% to 6.796'89998975%5" with an associated recurrence rate of 09610 5%," There was an overall eduction incon stipation, which was attributed to resection of the redut- dant sigmoid colon. Continence was also improved in most patients, Luukkonen et ab” in a comparative study be- tween reetopexy with sigmoidectomy vs rectopexy alone showed that sigmoid resection did not increase morbid- ‘ty but tended to diminish postoperative constipation, pos- sibly by causing less outlet obstruction. Ina prospective randomized study ofretopesy with and without rectopexy, MeKee etal in 1992 showed that pa Uients with rectal prolapse who underwent abdorninal rec- topexy alone hada high incidence of constipation. Theyalso showed that patients having recopexy alone had a higher pressure inthe rectum lor a given volume of isotonic so- dium chloride solution infused. They postulated that this was duc to kinking between the redundant sigmoid colon tnd the rectum atthe rectosigmoid junction, and that the addition of sigmoidectomy appeared to alleviate this pos- sibly by removing he redundant loop of colon that may kink and cause delay in passage of intestinal content Anterior resection was frst deseribed by Mult in 1955," allhough the fist successful operation was performed by Stabins in 1047.”* Ina retrospective study of 28 patients, Theuerkaul etal in 1970 noticed a4% mortality rate and 496 recurrence rat aller anterior resection with improve- rent of continence in 63% of cases. Schlinkert etal” in 1985 reviewed the Mayo Clinic experience with anterior resection for complete recal prolapse in 113 patients dir- ing a 12-year period. There Was 4 9% recurrence rate, a 1% mortality rate, and a 50% improvement in contie rience, Cirocco and Brown" performed anterior resee- tion in 41 patients with complete rectal prolapse. ll of these authors claimed thatthe advantages of this opers- tion was that it was familar and frequently performed, did not require foreign body or rectal suspension, and had ‘withstood long-term scrutiny in terms of both recur rence and associated complications. As with sigmoid re- Section, this operation has not gained popularity Laparoscopic Rectopexy Compared with laparotomy, laparoscopic rectopexy has the advantages of reduced pain, shortened hospital stay carly recovery, and early return to work.” The proce: dure involves either suture oF posterior mesh rec- topexy, with oF without resection. It has gained popt- larity as tis relatively simple and easily accomplished and resection with anastomosis is avoided,!=2"°"8°" The mortality for laparoscopic rectopexy’ ranged be- tween 0% and 39%, with recurrence rates ranging from 0% 10 10% in follow-up of between § and 30 months." These studies have demonstrated that this approach is as elective as the open method in the treatment of rectal prolapse, and the elect on con- tinence and constipation depends on the type of ree- Lopexy performed 1.1909, Boceasanta tal compared the functional and clinical results of laparoscopic rectopexy with those of the copen technique in 2 similar groups of patients with com plete rectal prolapse. The laparoscopic approach was asso- (REPRINTED) TECHSURGVOL HD, JAN TS ciated with reduction in postoperative hospitalization, but there was nonsignificant prolongation of operative time and the higher cost of surgical materials, The shorter post- operative hospital stay determined an overall reduetion in the total cost of lapatoscopie rectopesy. In the same year, Xynoset al® compared open and laparoscopic resection 6° topexy and conchided that resection retopexy for ectal pro- lapse can be performed safely via the laparoscopic ap- proach. 1n 2002, Solomonetal” reported ona randomized con- trolled study of39 patients undergoing abdominal rectopeny. Nineteen underwent open procedures and 20 had laparo- scopicprocedures. They concluded thatthe aparoscopictech- riqle had short-term benefits in terms of return to normal dict and mobility eatir discharge from the hospital, and less morbidity. These results were paralleled by a reduced neuroendocrine and immunologiestressresponse. Nolong- term differencesin constipation, recurrent prolapse, orm provement in continence cores between open and laparo- scopicapproacheswere identified Laparoscopicalyasisted rectopexy hasalso been described with ood results, equiva Tent to those of open and laparoscopic reclopexy Place of Prosthetic Meshes in Rectopexy The use of prosthetic material in rectopexy has been chal- lenged in recent years. There evidence that complete en- cirelement ofthe rectum (Ripstein procedure) may lead to crosion of the foreign material with subsequent fistula for- ‘mation and stenosis in approximately 7% of patients." Fur- thermore, Kuijpers reoperated on 4 patients who had had posterior rectopexy with T-shaped polytet mesh several years previously. None of the patients had actual prolapse recurrence, but both of the “horizontal” legs of the mesh had retracted to the promontory and were ineffective as a fixation device. Therefore, Kuijpers believed that the pur- pose of using an implant to evoke an intense fibrous tis sue formation is not always achieved by using prosthetic ‘material In 1972, Penfold and Hawley" conceded that the polyvinyl alcohol sponge tends o fragment but persist it human tissues for 5 years. Indeed, many authors" now be- lieve that reetal fixation by suture only seems sufficient, with reported recurrence rates of 3% of less."°*! Role of Division of Ligaments The left colon and rectum receive retrograde innerva- ‘don from neural efferents running through the lateral ligs- ‘ments; thus, lateral ligament division during rectopexy hhas been suggested to denervate the rectum, causing post- operative constipation." number of studies have looked atthe effect of the division or preservation of ligs- ‘ments and are shown in Table 5 and Table 6, The results shown in Table 5 suggest that the lateral liga ments were usually divided, perhaps because there isa trend, toward improved continence. Although fecal incontinence ‘may have been decreased, constipation either worsened or remained the same. Only 4 studiesaddressed changes rest- singand squceze pressures, Threeof these studies showed im- provement in both pressures, while only 2showed improve- ‘ment in squeeze pressures, Table 6 shows studies of more than. LO patientsin whom rectopexy wasaccompanied by pres (©2003 American Medical Association. AI rights reserved, Downloaded From: http:/jamanetwork.com/ on 10/25/2016Table 5, Effect of Diision of Ligaments on Outcome of Rectopexy Resting squeeze s M__besign Te rossure,% Pressure, % Continence, % constipation, % Open Novel tal 1004 31 Prospactve lyin! alata is Ns BH ay ‘spore 32 Prospctva Suture ns is 151) a1) Yt et al? 1908 48 Bevspctie Posterior mesh Ns Ns ao uo Sragla ot a 1904 46 Batospecive Pastor mesh acy 59 9G) ay igh 100 ns Posterior mesh aC) 9) tt) us Molen etal 2000, 10 Prospctia Pastor mesh 50) no. Ns No Gocco and Brown" 199341. Ravospectie Aner secon ns Ns 48E)10K)—18(4)286) Safa etal 1900, 20 Prospactva_Pasttor mesh 1914) su) Ns is ‘aparoeopie Xymos tale 1900, 10 Prospactva —Raseion + sure 25(+) 4G) 1004) Na Hea etl2000 25 Prospctva Suture Ns Ns 5004) 1414) Zitl etal 2000, 20° Prospactia _Posttor mesh By 7) 7G) No Benoit al 2001 48 Retospecive —Rasecion + sure S NS 100(4) Variable Abbrvations: MA ot apical; NC nochange; HS, not state), improvement (-), worsen, Table 6, Effect of Preservation of Ligaments on Outcome of Rectopexy Resting squeeze Nessa Te rssure,%4 reste,“ Contnence,% _contpation, Ope bac at a 1005 42 Prospective Resection 9K) 124) ata 18(4) Wide etl 1058 447 Prospective ‘ipsa Nis Ns (4) 70) Holmstom atl 1986 108 NS pst nis ns a4) 70 Sehueeta™ 2000112 NS Rist Ns Ns minor ara) Galland abou" 1007 37 ——~Prospactve Pastor mesh Ns ns w is anna tl 1996 5 Prospecive Suture Ns ns 15) BU) Br at 1007 24 Suture Ns ns ery) is atta! 1085 138 Resection Ns ns 38(4) eas) Luukkonanst al 1992 30 Prospectve_Pasttor mesh Ns ns 6) (4) tos tl 100 | 85 Revorpecve Posto mesh Ns Ns 25(4) 2) Tiandaatal” 190192 —atrospacve—petein Ns ns 18) No 18 Rewospectve —Rasecion Ns Ns ny), 564) olen etal 2000, 8 Prospective Pasttor mesh 5(4) 74 Ns is Shu ta 1006 2 ons Rips 20(4) ny Ns ns Scag ota 1004 16 Revorpectve —Riptin 1204) 24) Ns ns Lichawcetal’*2001 25 __Prospectve Pastor mesh Ns Ns rR) 50) Taparszopie Stenson otal 1998 34S Resecion + suture NS ns 70.4) easy Kallokumpu tal 2000 17 Progpectve Suture Ns Ns ay 703) Boceasntactal 190910 Prospectve Pastor mesh 154) 10(4) w No Bruch et a= 1900 22 Prosp Suture 3) Byala) 154) Abbrvations: NC, na change: MS, ot tated (+), mproverent (3), worsening crvation of lateral ligaments; there was an overall improve- ‘ment in continence. Although results were conflicting, there \wasa tendency toward reduction ofconstipation. Again, only 4 studies addressed anorectal physiological changes after rec- opexy; there wasan overall increase in resting and squeeze pressures. Brazzell tal” performed a meta-analysis of ar- Uiclesreportingon surgery forrectal prolapse. They concluded that division, rather than preservation, of thelateral ligaments was associated with less recurrent prolapse but more post- operative constipation although these findings were found insmall numbers. Themajor limitation of thismeta-analysis| \was that only 2 studies (one of which was an abstract) ad- dressinglaterlligament divstonor preservation were included inthemeta-analysis. Insumnmary,t would appear that pres- cervation of ligaments associated with an improvement in continence and a reduction of constipation. PERINEAL PROCEDURES The advantage of perineal procedures is that they avotd laparotomy, which makes them well suited for high-risk patients, Thereare 2 widely used perineal procedures: the Delorme procedure and perineal rectosigmoidectomy (Al- temeier operation). The Thiersch procedure, which entails encircling and thereby narrowing the anal canal, does not eradicate prolapse but merely prevents its further descent (©2003 American Medical Association. AI rights reserved, Downloaded From: http:/jamanetwork.com/ on 10/25/2016Table 7. Results ofthe Delorme Procedure for Rectal Prolaps Torta, ecurence, —_ Folow-p, s N_bosn Ho. (4) Continence, "4 constipation, "4 Ho. (2). me Pacer aa 1008 8 “Ravospeaive 0 @ uy 5a) » Lech 1005, 85 arospecive 112) 50) 100(4) 1118) = Agatha etal 1007, 8 Retospeae 0 wo Ns 3138) 2 tweet a 004 41 Ratospeaie 1128) sa) Ns Bia) a Yt t al? 1998 2 Ratrospecive 0 Ns Ns (42) 38 King el 1006 6 Retospecive 0 a) 100(4) 4417) i" Wats and Themgson!”2000 101 —Ratospctve 4 (4) 4) BO) en, % Sengpat etal 1904 2 us ° 6) 504) 4125) Fa Leman tl 2000 ML Ratospesive 0 2) a4) 0 8 Tobin and Sot 004 8 Prospecie «0 a0) NA 11 28) 2 Abbrvations: NA at applizable Snot state, (+), improvement (-), worsen, Table 6. Results of Perineal Rectsigmoldectomy for Rectal Prolapse Toray, TRecuronce, — Falow-p, s NM bosign __Levatorplasty No. (*4)__Contnence,%¢ constipation %« He) mo Teesuet a= 1009 10 NS Yer 0 7 18 ° 2 Rananwam sal" 10072 NS No 0 eri) us 416) 20 Doan etl 10nd 10 Prospectve No o a us 100) 8 tea 1085 38 Retospectva Wo 0 6(4) 48 ° 2 2 Wiliams tal 1992 56 —~eogpecive No ° 0) us 60) 2 0) 2 No 18) a) us ° 26 2 No o wo uC 4013) 30 106 No 0 Ns us 319) 28 183 Retrospective No us 3c) a1) 20118) a Wiliams tal 199211 ‘spective Yor us ai) us ° 2 Agathan tal 1907 21 —~ospecive Yor o a uc 16) 30 Prasdstal* 1088 25S Yes 0 (4) us ° ns ‘Abbreviations: NS ot tated (+), improves. “Levatrlasty performed in canner patents by providing mechanical support and hence it isassociated witha highrecurrencerate (33%-44%)."°***Given thesalety of modem anesthetic techniques, there isno role for its use Delorme Operation This procedure was described by Delorme in 1900" and involves dilation of the anus, separation of the mucosa from the sphincter and the muscularis propria, and the division of the mucosa together with the plication of the muscularis propria. It has an additional advantage of excision of a concomitant rectal uleer if present.” The Delorme procedure represents a surgical alternative for patients with prolapse who may be unable to toler- ate a more extensive operation, such as the elderly, frall patients, and those who are medically unlit for major surgery.°= Table 7 lists patients undergoing the Delorme op- eration, with reported mortality rates of 0% 1o 4% and recurrence rates of 4% 10 38%." Oliver et al successfully performed the Delorme procedure in 41 pa- sats with a mean age of 82 years who were deemed un- fit for major surgery because of age or comorbidity. They pointed out that important pitfalls in performing the pro- cedure were weak orabsent sphincter tone, perineal de- Scent, and previous sphincter injury. There was a gen- cral improvement in continence Pescatori etal combined the Delorme procedure with sphincteroplasty in 33 patients, with good results achieved {70% of patients. Continence improved in 70%, and in 44% constipation was cured. They conclided that the De- lomme procedure combined with sphincteroplasty seemed indicated when both clinical and physiological ndings showed a concomitant severe pelvic floor dysfunction. However, many other series without sphincteroplasty have shown improvement in continence." Factors associated with faire for the Delorme pro- cedure inchide proximal procidentia with retrosacral sepa- ration on defecogeaphy, fecal incontinence, chronte dh arthea, and major perincal descent (>9 em on straining) In the absence of these Iactors, the Delorme procedure provided a satislactory and durable outcome.” Perineal Rectosigmoidectomy This procedure was first advocated by Miles” in 1933 and subsequently by Altemeier etal in 1971." IL involves a full-thickness excision of the rectum and, if possible, a (©2003 American Medical Association. AI rights reserved, Downloaded From: http:/jamanetwork.com/ on 10/25/2016portion of the sigmoid colon. It has gained general ac- ceptance for use in elderly patients in Noth America® Table & summarizes the dats on patients who under went perineal rectosigmoidectomy. The reported over- all morality rates ranged from 0% to 5% and recurrence rates from 0% to 16380-81080 The postoperative course alter perineal rectosigmoidec- tomy is generally uneventfl, patients have minimal pain, oral intake can generally be commenced within 24 to 48 hours after surgery, and bowel function returns within a few days of surgery.” The potential complications in- chide anastomotic bleeding and pelvic sepsis and, al- though leakage is uncommon, ension and poorblood sup- ply can cause anastomotic dehiscence” Extreme care must be taken not to pull the bowel too ightly while avoiding ligation ofthe mesentery too far proximally. Since ecur- rence probably reflects inadequate resection, care must be taken to mobilize the entire redundant rectum and to per form the anastomosis within the pelvis" Perineal recosig- rmoidectomy i wel suited for male patients; patients with incarcerated, stangulated, or even gangrenous prolapsed reclal segment; ad patients who have had recurrence al- ter another transperineal repair°"=" Perineal rectosigmoidectomy has yielded poor func- sional results with respect o incontinence, urgency, and soiling, as well as high recurrence rates because ofthe loss of reservoir capacity due to a rather narrow colon above the anal anastomosis, together with some reduction in anal sphincter funetion.*"""* Yoshioka etal” deseribed pouch Perineal rctosigmoidectomy as ameansol overcoming this problem and suggested that this procediie reduced recur~ rent prolapse probably because rectopexy sures were used to ix the transected colon against the presicral fascia, How ever, prospective randomized tral atthe institution of 2 ofthe 3ofus (MKB. and S.D.W.) had tbe discontinued because of the large number of patients randomized to pouch anal anastomosis in whom. viable pouch could not be made to reach the anus. Reduction in resting anal pressure and compromised compliance make conventional perineal rectosigmoidec- tomy an unphysiologic procedure that resulsin increased soilingand frequency of defecation’ Some authors have therefore suggested the addition of levatorplasty to perineal rectosigmoidectomy. Theadvantage of posterior levatorplast is that recreates the anorectal ange, which sccm toimproveanal continence.” Thisconcomitantleva- torplasty achieves not only a more significant improve: rmentincontinence butalsoalovwershort-term recurrence rate than either the Delorme procedure or perineal ree- tosigmoidectomy alone."® When comparing the vartous perineal options (perineal rectosigmoldectomay, perineal rectosigioidectomy with levatorplasty, and Delormepro- cedure), the perineal rectosigmoidectomy with levator plasty has the largest recurrence-free interval, the lowest Fecurrence rate, and the most salutary effects on const pation and incontinence. Perineal ectosigmoidectomy is thereforenext best and the Delorme procedure isthe worst of the 3 perineal options There is general agreement that perineal rectosig- rmoidectomy is often the best operation or extremely eld- erly paticnts or individuals with profound comorbidity in whom an abdominal procedure might be contraindl. (REPRINTED) TECHSRGVOL HD, JAN Ts cated," IL is also suitable forthe elderly or high-risk palicnts with incontinence because @ concomitant leva- toxplasty can be performed.""*"" COMPARISON OF DIFFERENT PROCEDURES AND APPROACHES. Scaglia ct ab* compared 16 patients who underwent pos: terior mesh rectopexy with 12 who had Ripstein ree- topexy: Neither procedure improved symptoms of const palion or evacuation problems. The criticism of that study fs the very small numbers of patients. Novell et al" com- pared the polyvinyl aleohol sponge technique in 31 pa- ‘ents with the sutured rectopexyin 32 patients. There was, ‘marginal improvement in continence and reduction of com- stipation with the suture technique. Those authors con- cided that becatse of the small but definite risk of inf tion associated with the sponge procedure, it should be abandoned. In a prospective randomized study. Luuk- kkoncn etab in 1992 compared abdominal rectopexy with sigmoidectomy in 15 patients vs posterior mesh rec- topexy without resection in 15 patients. Sigmoid re tion in conjunction with reetopexy did not seem to in- crease operative morbidity but tended to diminish postoperative constipation, Sayfan etal prospectively com- pared 11 patients who underwent sutured rectopexy and resection with 12 patients who had posterior polypropy- lene mesh rectopexy and concluded that resection re topexy’was comparable with posterior mesh rectopexy tn 2001, Benvist etal” published their results of lap- aroscopic ectopexy in 48 patients. They evaluated lap- aroseopic rectopexy’ using mesh, suture, and resection and conchided that laparoscopic rectopexy was safe and clfective. They also found that there was no difference among the 3 groups in tems of continence; mesh ree~ topexy conferred no advantage over suture rectopeny. tn 1999, Kim etal reviewed their experience with the treatment of 372 patients with complete rectal pro- lapse during a 19-year period. They looked at choice of operation, currence rates, and functional results and showed that abdominal rectopexy with bowel resection was associated with low recurrence rates, Perineal re tosigmoidectomy provided lower morbidity and shorter hospitalization, but recurrence rates were much higher They pointed out that perineal rectosigmotdeetomy has appeal asa less intensive procedure for elderly patents or patients in the high-risk category. They conceded that paicnts who underwent perineal rectosigmoidectomy ‘were more likely to have associated medical problems. Yakut etal evaluated their results in 94 patients in 1998, They looked at the results of the Delorme proce- dure and of abdominal resection with or without ree- topexy. They noted thatthe most important complica tions were sextl problems in male paients who underwent posterior rectopexy procedures. They concluded that the Delorme procedure, posterior rectopexy, and resection pro- cedures were effective surgical operations for the teal- ‘ment of rectal prolapse but that extensive pelvic diss tion during the posterior rectopexy might create serious sexual dysfunction in male patients Deen et al" compared suture and resection ree- topexy with perineal rectosigmoidectomy. They noted that (©2003 American Medical Association. AI rights reserved, Downloaded From: http:/jamanetwork.com/ on 10/25/2016sbdominal resection rectopexy with pelvic floor repair gave better functional and physiological results than did perineal ectosigmoidectomy by preserving both the n- ternal sphincter and the rectal reservoir. There was. sig- rficantly higher maximum rectal resting pressure in pa Uicnts with resection rectopexy 1m 1997, Agachan et al” compared the Delorme proce- dure, the perineal rectosigmoidectomy, and perineal r= tosigmoidectomy’ with levatorplasty. The recurrence rate ‘was highest with the Delorme procedure; postoperaive con- Uinence was improved in all 3 procedures. The postopers- Live incontinence core was loves inpatients with perineal rectosigmoidectomy with levatorplsty. The median hos- pital stay was similar forall groups. Recurrence rates were 58% for the Delorme procedure, 13% for perineal reetosig- ‘moidectomy, and 5% for perineal rectosigmoidectomy with levatorplasty Postoperative anorectal function and anoree- tal physiologieal characteristics were similar forall groups. The authors concluded tht perineal rectosigmosdectomy with levatorplasty was a safe procedure, resulting in sig- nificantly better short-term funetional outcome than et ther perineal recosigmoidectomy alone o the Delorme pro- cedure. Concomitant levatorpasty achievesnot only a more signilicant improvement in continence but a lower short term recurrence rate than the other 2 procedures twould ippear that the functional results of the perineal proce- dluzes compare favorably with those of ablominal proce- dures in terms of restoration of continence, with less fre quent severe morbidity.” However, high recurrence rales aller both primary and repeat operations should be explained to patients when their surgieal management is planned. **"" Extensive divertiular disease may pro- hibit effective and complete proximal mutcosectomy i he Delorme procedure. Inadequate resection may predispose to carly recurrence of the prolapse."* Since perineal rectosigmotdectomy is difficult to per= form n patients with asinall prolapse and in those whose prolapse isnot fall thickness in its entire circumference, Takesue ct al suggested that ifthe prolapsing rectal seg” richt is shorter than 3 to 4 em, a modification ofthe De- lonme procedure is better approach than perineal ree- tosigmoidectomy. We agree with this assessment (CHOICE OF OPERATION It scems reasonable that patients who are fit for surgery without comorbidity should be offered abdominal rec- topexy, as i is now associated with very low mortality rites, The abdominal operation with the lowest recur- rence rate should be offered to the medically ft patient. Even though abdominal operations have a higher mor- bidity, the fit patient is presumably capable of withstand- ing complications and should be given the best chance to cure the prolapse. This review has established that ab- dominal operations not only offer lower recurrence but also a greater chance for functional improvements, Su- ture rectopexy is capable of giving good results, and the addition of the posterior mesh does not offer additional advantage; rather, it has the disadvantage of introdue- {nga foreign body. There seems therefore little to choose between suture rectopexy and posterior mesh ree- topeay. The polyvinyl alcohol sponge rectopexy is asso- (REPRINTED) TECHSRGVOL HD, JAN Ts ciated with an increased risk of infectious complica- tions and has largely been abandoned. Posterior mesh rectopexy with other types of meshes has reasonable com- plication rates and recurrence rates. Theadvantage of add- {ng a rescction to the rectopexy’ seems to be a reduction {n constipation, This procedure therefore seems suited to patients with a redundant sigmoid colon and a his- tory of constipation. The Ripstein procedure has been as- sociated with problems of constipation that either pe sisi or postoperatively worsen, iaving chosen an abdominal resection ectopexy as the best option for the ht patient, the next decision is how to address the lateral ligaments. Preservation of the liga- rents scems to have the advantage over their division in terms of continence and constipation. There ate fa fewer studies addressing the iniluence on resting and squeeze pres- sures alter both approaches, but there seems to be bent to preservation of ligaments. Further studies are required toassess the eliacy of division and preservation of lateral ligamentsin these operations. However, for now the choice of division and preservation of ligaments depends on the Surgeon's experience and preference Laparoscopic surgery has the advantages of les pai, shorter hospital stay, carly recovery, and early return to ‘work as compared with laparotomy. Apart from these ad- vantages the results ate similar to those with the open procedures irrespective ofthe method used (suture, re section, or posterior mesh). Therefore, where expertise {savailable, this approach may be preferred Perineal procediresare often use fr fal patents with extensive comorbidity and individuals who are not ft for ‘major abdominal surgery. Moral rates are accepablecon- sidering the typeof patient in whorn the procedures done. The higher recurrence rates mandate that paicntsbe fore warmed that there may’ be need for a second operation Whether to do the Delorme procedure othe perineal re tosigmoidectomy will depend on the prelerence and ex perience ofthe surgeon and, oa lesser extent, on where the physicians practicing, However, the Delorme proce- dure is associated with even higher recurrence rates than {spperinealrecosigmoidectomy. In addition to redheing the potential risk of injury tothe pelvic nerves, a perineal ap- proach may be preferable in young male paticats Favorable outcome could be achicved alter perineal pro- cedures by applying stringent patient-seeetion criteria Perineal proceclires represent surgical alternative for pa- tients With total prolapse who may be unable wo tolerate a more extensive operation sch as the elderly, frail pa- tients, and those who are medically unfit for major sur- ery such as abdominal rectopexy. The Delorme proce- dure may be useful i dare is insuicient length of prolapse to perform a perineal rectsigmoidectomy "=" Forall perineal procedures, the high recurrence rates for primary and repeat operations should be explained to patients when their weatment is planned. Perineal re tosigmotdeetomy is well suited for patients with inear- cerated, strangulated, and gangrenous rectal prolapse ‘whereas abdominal rectopexy cannot be used for these situations, even in fit patients In recent years, there has been a wend toward offer {ng perineal rectosigmoidectomy to healthier patients. Although perineal rectosigmoidectomy can be per- (©2003 American Medical Association. AI rights reserved, Downloaded From: http:/jamanetwork.com/ on 10/25/2016formed with minimal hospitalization and disruption in the patient’ Ife, the recurrence rate is in the range of 168%." For younger lemale patients the benefits of perineal rectosigmoldectomy being a lesser procedure must be Weighed against a higher recurrence rate* Among fac- tors to consider in the selection of a treatment option are the age and health ofthe patent, functional results, and the benefits vs the advantages and disadvantages ofthe surgieal technique." CONCLUSIONS The problem of complete rectal prolapse is formidable, with no clear predominant treatment of choice. Abdominal pro- cedures are ideal for young fit patients, whereas perineal procedures are reserved for older frail patients with sig- nificant comorbidities. Results afterall abdominal proce- dures are comparable, Suture ectopexy seems adequate in curing rectal prolapse. The superiority of mesh rectopexy hhas not been demonstrated, and meshes add a foreign body and increase the risk of infection. Suture and mesh rec- topexy'are sill popular with many surgeons, and the choice depends on the surgeon’s experience and preference Whereas sigmotd resection alone and anterior resection are obsolete, laparoscopic rectopexy has results equivalent to fr better than those of open rectopexy. Laparoscopic st- ture rectopexy is preferable because itis simple and easy toperform. Perineal procedures are useful for patients who are not fit for abdominal procedures. Perineal rectosig- ‘moidectomy seems better than the Delorme procedure and, i possible, levatorplasty should be added, Accepted for Publication: November 25, 2003, Correspondence: Thandinkost E. Madiba, MMed (Chir), FCS(SA), Department of Surgery, University of Natal, Private Bag 7, Congella, 013, South Africa (madiba @ukzn.ac.za). Es} 1. eas LK, Ln, in BA. Thebes operant cal prolapse. Sg lio Northam 007.7470 2 Fateerama Rl, Cosa MA Rec prolpse, ral inussuscoption, eto and salir ee yams Gaston Gin Neth A. 201 3019-22 4. log. Ble Als et Anaetuncton npn wh compat ‘prope ins tne coninantaninconet nda Rev Esp no Dig. 108690794308 4 Bagi BSoean Pret ofthe rectum: ui with hth ‘Dis Calon stam, 196811290-7, 5 ales HC. Test of op cal rosea ar, ow, endo ene ples ors? ov J Su, 1021622580. 6 Nichols Ral rips andthe lay ayer, An tl hr 128 fssr-62, 7. Yala M, Kayako, Sse eS ema of ta! pro las: etospcive anit cases. n Sug 10088353 55. 8 sil Rohenbargar DA, Golda SM. Rata prolapse, Cr rb ur. sane 307451 ©. Sirois, olism, Jgut eta Rect adoption distension np en with overt eal relapse. J Surg 100885 1527-1522 10 At PT Hanan KM, Matin Wl Futana st fos et ‘et of etapa over an ar peri: pass on sabia ‘proach Ds Cola acu. 0882 8680 1, Bre J, Seouen WR. Boma WO Lorem ess of sure etpo in ates hcl canines azcied wthneompat rts prota, De ‘ate Recum 1097 40 128-1232 12. ftnen KM, Matinen AU, Anan , Hine Pinal and manos rn 20 21 2, a m 5 6 a. 8 Ey Fa Fy 0 4 2 6 “ auton nal pincer funon inp with ta proapse Am Sug. ‘angst ane 40 igh WR, Fig JW, Alexander Wians J Ress of Male mesh b- ana topo el pelase 1D consecive paen rSur 185 raze Croce row AC Antsraectonfethtrsmantt rectal rp 20 ear exponen Ao Sur 10033825. 250 ig MR Sholr Aeneas of eoanicnton pars whe {al prope an encanta, Br) Surg, 1847182905, Mano ¥, Hatin C. Compare rouse: he nator an funtion raul of ueament yan ended abcomnalrcpen. BJ Sug. 18h; T5497 Tz, Faso WW, Church JM etl Risin procedure isan ecb we ret er acl proapse wth costpuben. Dis Colon Fectum, 109335: 0507 lack WR, Wis NS, Holi HM a Presue a prolpse—the aus of soar rc alcerton Gu 108728 128-1238, ostin C8. Trextont of massive ec prolpse. Am. Sug 152886871 Cait. Szo-romaray oan ofthe rectum or compe ecal pralapse Pra Soo ed 195952 sup 105. Cae AE Rectsural suture ato fr cml prose inthe he fealand the omercod. Br Sug 10837052252 Novel 8, Osborne, inset MC evi A Prospective random ilt aon spange versus sutured ectopeyforulhchnss etl props. Br Surg. 180430436, (Ga aor U, iran. stl Functor se sterol aera ‘apn ort pps essseptn Fur Sug TO 6200531 ana AK sta MK, Kura Simp sire sural rctapan com- let ractal props in ats. Er Sur 19965:162 12-1. alkinp, Vroe Sein. aparszopi epi of cal rope 2 prospect stu xaurting sug acme ad hagas in ygtoms and Bove uncon Sug Endse: 2000 1530-640 ia SM, Harel J Hurley tal Laaascop suture retpon without ‘oni efecto rfl hls ta prope. iCal Ret, ooo 98 4, ele ty BL Misr J, Soret resent ta prope p> roscope suture etpen- Sug Ende 100 13258861 ‘rch HP, Healt Seideck, Schwan O, aparece oe ‘alproaps an uit sbstucton. Os Gln Rac 1002 116-1104 Banat Ttider Goud, tal ancbonal est 0 yas tr apo- Scop etpeny Ar J Sug. 2007182168473 Plc, Pay Px of ln spnge pant for camel talproaps att Mark's Hospi Br Sug. 17250845 408, ‘Morgen, Part Wi Klugman lo pang nthe regia compete rac proase Br Sug. 17250841 06 Seal M, Fas S, Hagen Tet Abiornal rectopon for etl pops: infarc surgi acgueonncionalouzone. i Cao ecm. 108 sree Notas MU Te uo Mrslane mse in atl prope Med 17366: 696 Safa, Po M, Aranda Willan Keighley MRB Suture postr ab- tain retpen wit sigma compare with Mie recon rca prolapse. Br Sur. 1H07.188-445 {rene ,ifoen Une. Abdoninal copy wih sigma ‘any vs rctpeny alone fr ect popse: prospective, domized tu, lod Cart O 10827210-228. Wi 6, ees, Noterg eal Cnzal an tetra resus of bdo actor wit absortabl mesh rato wexment of comple acta prope urd Sug. 1998 159301-205 GY, abe Carparisun of olygiele acd andplpropylne mas fox ractoat int tenet of ctl rps Eur J Sur, T57 T6458 Molin , Kujpers HC, van Hak F Ets fet mebization and aa gamut isin an nora arreal uncon. Ds Clan Rac 200, 28-1287, imps Care, rus Varryen Laparoscopic rectopan aco ing Was. Sug Enese 100013180141 Daz, Henry IM, Gullo Pl et Supe tparsepi retary for rectal rouse. Sug Endose. 1005, 0301-308, Bocas, Vert M, Reto MC, Lapactonic s apaascope ‘ape in camplt ee pals. Oy Sur. 186 T6415-18 Zl TT, Manele Hau 8, eal ncn ests ater paoscop ‘ape oracles. J asamest ur 20004652641 Wes New open oct poapse, Pac Soc Me 105052602603 ‘aM scar, Absorb resh th rset octal props. nt CalrectlDe 068 2181-43, i, Po Soe (REPRINTED) TECHSORGVOL HD, JAN Ts (©2003 American Medical Association. AI rights reserved, Downloaded From: http:/jamanetwork.com/ on 10/25/20166 « a. a *. 0 5 2 2 4 8, 6 ea a ey oo. a. 2 «. 6. 8. a. 7. 1. Downloaded From:: hanasais 8, Wear ,Hliers Je Th kins of ee sy Thee mates usa retary tha without aol sein or ral Potpse n-J Cbrecta Dis 1005 112-8. Pa eomot Tae. Tas-saletapenyorecurantcompee rectal pouse. Sug Toy 109620970972 Lake SP, Mancack BD, Lewis AA Management of pic sepsis ater halon rectopen. Dis Cob Rectum 19842756950 Ross AK, Thomson JPS Maogement of recon ater pros abinal rectoon Wels procedure) Br Su 186076810612 Wel J Shaper Meira Een , ta De probe er peinen is tach actopne mits hao uve behandun. Chiu 197 seer, SpakmanCT, Man MY, hl, Kame ML gant cision ingrcteen cases conspaon bt reves caren prose th andomoed tity. 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Sala A Reteberer DA, Golda SM Colonie resecian inh eaten ot opera rouse et JS. 88541-12285. ‘Stveson AR, Sits AW, Luiey JV. Laparoscopic assisted resin re top oracle ard aun foo. Dis Calo cum 108; res ‘amu hatcinda Ras ta Rec rolape ase forthe est pecan Ar Surg 2001 7822627. Was 1, Rtobeger Oh Bue Jt a. The mangement of proc: 20 Yous xprne. is ao Rectum, 19852696102 Do KI Ga, nga Kaghsy MAB, Abdominal section rexopony th pe tor epa versus pera ectsigmoleom) ape Horr ator tulsa rope Sur TOOT 302- 308 HuterF, Sin H, Swe JR Functonl aut er teatnan ct ro- las wih ecopen and sigmoid secon Won J Sug 100511381, Kin0-5, Teng Wong WO, at Compt rapes: even ot mar ret nd ete, Ds Cl Act TH 2460-460 no. Gysae Tans tal Reseton etopen foetal te prose appach Sug Endse. 19861582 84, Mees RF Laue 0 Poon FW, ta A prospec randomize stu fa oma ectopey with nd wiht signet in cal pola. Sug 6 acl bse 0078445 48 Muir ES Rectal pope, Pac Soc Med. OSS82-4 prove tate Rpetin ret eect? (REPRINTED) SRCHSURGNVOL TO, AN TOS m 8 78 Shin Si Anew surgical procedure fr comple recto {abl sent ae repo. Surge 1S1-2008-108. Theat Fi Burs OH HJR. Rectal rose custard surgi ‘eament A Surg 10707810435. Sehnert A. Bert A, Wot 8, Peberao J, tir sein or com- teeta prose. Ds Colon acum. 86528400412 Baer, Senagor A, Lich A Lparascape asad pan eect: rata fs ect asus. Ds Colo Rectum 190535 100201 Soman, Young, rs AA Robes A Randomised il etp- ‘sco vrs pen onl recap fort prope. Surg. 200 ena0 nhord Gs Per RE, Thoreon AG, Christensen MA. Rata proapartnd ‘heray ito oeign mate tnd Surg. 10884 128-128. LehabeP, Ara, Goasqun Post eipe the peictor An siento rectal pola AJ Sr. 20018246569, inthe men 7, Brazel Macho P, rant A Saray comple ec prolps in ats ‘Covran Daas Ss Ray. 200020001758, £1, Dita CO, Pembertan J, Pcl pouches fx th trata of ome rat proape Meh J Surg. O60; ata Daooe Sure rate es roses u ect tzu pour econ dle scuese lou retzniaue, Bl er Sac Ch Pa 10269058. Pastas Meena, Sol VM, Zs Osler’ operation an phie- ‘sols real props and fal nconinencs. nalts. 1088 heaven ing, Rongios A, Evans Madan OW. Tha sla proce ue- {ul operation fr completed rectal pralase inte eer. An Sug. 196; esr 8. tab, Lach, Pre Ret of ae’ prac for ect ro- lope advantaes oa madd tchaigu. Di Calon Rectum 10853801 om ‘oacanF,Risan P Peter Jet Comparison of thas pti poc- res fort exen a etal prpse. Sou Med. 108790925952 ‘tr, Vachon, Enea TE eta Uslorms pred for comple ‘alprolpein sea celia patents: ananasis of paars, Ds Caen Fest 1042761467, ‘Wate AM, Thompson MR. Evaluation of slam’ procaea siet forfhicines ria prolapse. Surg. 200087 218-222, Lerman, Hugs, Diplo A Ealuaon ad outone athe Dele po durin the tment of ctl tt abtacten Di Calon Ram 200 eae Siler | Malt Cas Brant, Suse 1, Sastre BS tea ‘arial cal props opi by Oslo’ wansectal exisinDis Caen Fest 062967-33, Miles WE Recosgmoieciony 22 meted of weatmet fr proce et Pro Soc ed 033.26 4151452. ‘Atemeiar WA, Culberson WR, Schwengert, tal Nite year epince twin teen-age pens ep of ctl ropes Aan Su TIT 399- ‘ue, -ananujP,Valatsh KS, Ft, Pris tis ofr poser in ely highs patents ten-year expres Clon eum. 10; 7027-1090, Villans 6 RashbergerDA, Mao RD Goda. Teatertt el po laps th els by pene rectsigiecamy. is Colon Rectum 100 sree ‘eaneen 0, Werner SD, ani tt Pena retosgmeiactony nthe tlt, Ds Clon actu. 108836.787-72 Prasad ML Poa RK, Asan Hea Pil pocctony. poster c= ‘apy and postal letra hearer alec paapse. Dis Caen ‘stun 0862054752 ‘Yoshioka K, Ogun OA, Kghly MB Pouch peril ecosignldctamy ‘estar ntl st tan convent cesgmaiactony ney ns wh etl pls. Br Sug. 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